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GAINS Webinar- Effective Implementation of RNR in Treatment Court Settings

GAINS Webinar- Effective Implementation of RNR in Treatment Court Settings


– [Melissa] Good afternoon
everyone and welcome to SAMHSA’s GAINS Center’s webinar, Effective Implementation
of Risk-Need-Responsivity in the Treatment Court Setting. I am Dr. Melissa Neal, a
Senior Research Associate with the Policy Research Associates and I’m also the lead for communications out of SAMHSA’s GAINS Centers. We have just a couple of housekeeping slides to cover with you. The views, opinions, and content expressed in this presentation do
not necessarily reflect the views, opinions or
policies of the Substance Abuse and Mental Health Services Administration or the U.S. Department of
Health and Human Services. And throughout the presentations, we welcome you to submit questions. On the right side of your
screen you should see a Q and A pod which you
can click on and throughout the presentation, feel
free to submit questions and after the conclusion
of the last presentation, we will address as many
questions as we can with our presenters on the line. You also may have seen
a couple of polls pop up and we really appreciate
if you will participate. These polls will help us learn who has joined us today and understand our audience just a little bit better. And then finally, this webinar is being recorded
(electronic beep) and will be shared
following this presentation. Just a quick look at our agenda. First, we are excited to
have Jon Berg from SAMHSA here today to provide
some opening remarks. And then we have three presentations, by Dr. Faye Taxman, Dr. Douglas Marlowe and the Honorable Peggy Davis. And then, as I mentioned before, we’ll end with sufficient
time to cover your questions. So first, I want to turn it over to Jon Berg for some opening remarks. Jon? – [Jon] Thank you Dr. Neal. Welcome to today’s webinar,
Effective Implementation of Risk-Need-Responsivity
in Treatment Court Settings. Where per se you’ve taken the time to participate in today’s
informative webinar. SAMHSA is interested in promoting
evidence-based practices and for the assessment and
treatment of offenders, the Risk-Need-Responsivity Model is an EBP that is considered to be highly important. This is especially true
for delivering appropriate and effective treatment
for drug court clients and effective implementation
of drug courts. The implementation of RNR has been shown to effectively reduce recidivism and research has shown that
nonadherence to the RNR principles and service delivery
is not only ineffective but can also be detrimental to
offender treatment outcomes. RNR has been shown to
reduce criminal behavior and improve public safety and improve the distribution of treatment
services to offenders in prison, jail and community
corrections settings. We are excited to host today’s webinar to present the
Risk-Need-Responsivity Model and its implementation in drug courts. To provide a comprehensive system of care for criminal justice involved individuals. I would like to thank the GAIN Center and their staff for
their work in developing and facilitating today’s webinar. We are pleased to have three
very distinguished presenters today with great expertise in this area. Dr. Faye Taxman, Dr. Doug Marlowe and the Honorable Peggy Davis. At this time, I will
turn it back to Dr. Neal. – [Melissa] Thank you Jon. And now we’re just gonna briefly introduce our presenters today and
as Jon just mentioned, if you have done any
work looking into or look at studying RNR, you’ll be
familiar with our presenters. First, Dr. Faye Taxman
is a University Professor in the Criminology, Law and Society Program at George Mason University and she has tremendous
experience in the development of seamless systems of
care Models that link criminal justice with other
service delivery systems. Experience in reengineering probation and parole supervision services as well as organizational change Models. And she is received and
oversees numerous grants and active laboratories through agreements with Maryland Department of
Public Safety and Correctional Services and Virginia
Department of Corrections. Dr. Doug Marlowe is a Senior Scientific Consultant for the National Association of Drug Court Professionals, NADCP. He is a Senior Science and Policy Advisor for Alcohol Monitoring
Systems and as a Training Consultant for the Global
Institute for Forensic Research. Previously he served in a number of roles. As Chief of Science, Law
and Policy for NADCP, Director of Law and Ethics
Research at the Treatment Research Institute and
Adjunct Associate Professor at, of Psychiatry at the University of Pennsylvania School of Medicine. And he also serves as the Editor-in-Chief of the Journal for Advancing
Justice and is on the editorial board of Criminal Justice and Behavior. And we also have with
us, Honorable Peggy Davis and previously she was the
Treatment Court Commissioner of the 31st Circuit Court in
Missouri and also has worked as the Assistant Prosecuting Attorney for Greene County Missouri as well as the Public Defender
for the State of Missouri. And she is the past President
of the Missouri Association of Treatment Court Professionals. Currently, she serves
as a Senior Consultant for the National Association
of Drug Court Professionals and as faculty for the
National Judicial College. And so now we will turn
it over to Dr. Faye Taxman to kick us off with her presentations. – [Faye] Good afternoon
and thank you very much for this opportunity to talk about the Risk-Need-Responsivity Model, particularly as it applies
to problem-solving courts. So today I’m going to
go through very quickly, the framework for the
Risk-Need-Responsivity Model as it applies to a public health approach which is the next generation. A lot of people have heard of RNR more from a criminal justice perspective, but as the field has advanced
and new research has occurred, we actually have some
adaptations to that model. I first want to begin with the notion that we know a lot that works. For example, we know
problem-solving courts are very effective for
reducing recidivism. And this chart here, right here, which is, I have three colored box in it. The red box, meaning, these are the things that the scientific
literature has determined are not effective in changing
behavior reducing recidivism. Those items in yellow reflect in the areas in which we have emerging evidence and evidence that suggests that better implementation of those
particular initiatives would actually lead us
to improved outcomes. And then the third box
in green are those areas, programs and services and intervention that actually are effective
in reducing recidivism. And you can see on the
side that has, starts with Intensive Supervision,
those are the criminal justice per se interventions
and then the side on the left-hand side, my left-hand side, that talks about some of the
behavioral interventions. So problem-solving courts are effective but it also depends upon the type of treatment services that are offered. And as you can see, we know that cognitive processing groups, cognitive
behavioral therapy, therapeutic communities and
the use of medically assisted treatments are, enhance the effectiveness of interventions to
really change behavior. And this is important
because your drug court or your problem-solving
court not only should feature the core 10 components of NADCP, has articulated but also should
include enhancements to make sure that we’re providing
quality treatment services. The Risk-Need-Responsivity
Model was actually formulated in Canada by
Don Andrews and Jim Bonta. Their model was essentially
that, if we know the risk level of clients and if we know the needs that affect their criminal behavior and we provide them with
responsive programming, either programs that are prioritized, that includes social-learning model, cognitive-behavior models and tailoring that to the individual, we can
actually reduce recidivism. In the public health framework, we are adding in destabilizers, not necessarily just some
of the criminogenic needs, but some of the destabilizers
like mental illness, having instability, crude insecurity, that actually contribute
to negative outcomes. And we do that because
we know that in order for a person to do well in
a problem-solving court, not only do we need to
attend to their treatment, but we also have to
have them stable enough in the community so that they can benefit from those treatment services. The risk principle, RNR
principle is basically is based upon the risk principles, who should we target for
what types of services? Need principle, what should we target in terms of reducing recidivism. In other words, the drivers of recidivism. And then, responsivity,
where and how we provide these services and the
nature of those services to address the unique
characteristics of individuals such as gender, ethnicity,
age, culture, motivation. The risk principle is very important because the risk principle
essentially tells us that the more we target
a higher risk individual, the more likely those
individuals are to need intensive services in control
like those that are provided within problem-solving courts. And the need principle is
important because it tells us what behaviors we need
to really deal with. So we know that people
come in all sorts of mixes and in terms of their
combination of risk and needs and it’s important for
us to understand those to make sure that we’re
actually trying to target those that are likely to
have improved outcomes. Now, just clear definitions,
I know that you probably all have heard this, but risk
here refers to the likelihood that an individual will
engage in further behavior. Risks are the static factors,
the things that typically don’t change the first
time someone got arrested. The number of times they’re arrested, the type of criminal
history, the number of times they’ve been on probation and parole, number of times they’ve revoked,
age of first incarceration. This is what risk is about and these factors are not changeable. What is changeable is the needs. And needs here refers
to dynamic risk factors that are related to criminal behavior that can be changed and that
through effective treatment interventions and the activities
of a problem-solving court, we can actually make great headway. Here we want to deal with
issues like low self-control, anti-social personality,
anti-social values, criminal peers, substance
dependence, dysfunctional family and the deficits that people bring in terms of their education
and employment backgrounds. When we talk about substance use disorder, we all know that this is
a term that’s widely used and that good standardized
instruments are useful for helping us to decide at what level of severity is this particular person. And this is important because
problem-solving courts are more likely to help people
who have more severe problems because of the intensity of the services and the ability to provide a
number of wrap-around services. So problem-solving courts
are more likely to be geared and should be geared for
people who have moderate to severe substance use disorders and those who meet the, our
pharmacological criteria or need a medication
to assess with helping the person achieve some recovery. Stabilizers are something
that we should look at here and those are the factors that enhance the likelihood of success
for a particular person. These are the positives in people’s lives and these are the strengths
that we try and draw upon. Destabilizers are those
factors that make it difficult for clients to actually make some headway. And those include unstable housing, different types of drug abuse
and alcohol abuse disorders, mental health history, food insecurity. These make it hard for
people to participate and gain from treatment services because their focus of attention is really on just trying to meet the
day to day basic functions. The responsivity principle
tells us that we really need to think about the combining
the controls and treatment to address these static
needs and risk factors. Problem-solving courts are of course ideal for this because the court has the ability to do both treatment as
well as provide controls. What’s most important
though it to keep in mind the type of treatment
services that should be used to augment what happens in
the problem-solving courts and to be sensitive to
using treatment services that are better suited for individuals. So some good RNR public
health principles to consider are the use of the standardized
risk needs instrument. We refer to this as the third generation. That the validating, normed instrument, normed to your courts
and it should include the social determinants of health because knowing about food and housing and mental health status are really critically important to get good outcomes. Use of a case plan, targeting a person to appropriate programs and services based on their risk and needs. And then making adjustments along the way as the person succeeds
or has some setbacks. Okay, so let’s apply this more
so to problem-solving courts. So one thing we know about
problem-solving courts is the importance of making
sure the right type of client is in the problem-solving court. This is a study that was done in Kansas and the blue lines indicates
the reconviction rate of people that do not have the need that is identified in the
left-hand, on the y-axis. So, what this means and the right area indicates clients that
do have those needs. And you can see in all
of these different bars that the red bar is
smaller than the blue bar. That essentially means that when you match clients to the appropriate service, you’re more likely to get
reductions and recidivism than when you put people
into any program or services. And that’s an important
part because a big part of the problem-solving
court is to make sure we’re screening for
people who have the more severe substance use disorder
and who presents some public safety risk to the communities. Determining the level of
care is not always easy and it requires a
combination of risk levels, needs, clinical destabilizers
and lifestyle factors. All of these are important in
terms of how we would think about who’s eligible for
a particular program. With that, in order to help
people apply these principles, we basically have come up
with a hierarchy of needs. So clients who have substance dependence, criminal thinking, are
more suited for higher intensive services like
problem-solving courts. And clients that have many
of these destabilizers that are listed here, those are clients that need more wrap-around
services and more assistance in making sure that they
can meet their target goal. We’ve known for a long time that the match between putting people into
services and being able to actually deliver the needed service to a client is a difficult process. One that many problem-solving courts, prosecutors, judges, corrections, probation and parole officials,
all have struggled with. And so, my team has developed
a decision-support school to help people in making these decisions. We also as part of this
part, this toolkit, have a mechanism to be able to review the quality of the treatment programs and the court programs as well
as to do some gap analysis. And more information
about this particular tool is available on our
website and it’s something that SAMHSA has used with
many of their offender reentry programs in
the last several years. What’s nice about this particular toolkit is that it helps us to
basically take basic risk-needs information
and with some underlying algorithms that were
constructed in order to see what types of clients do better
in what types of programs, it makes recommendations on what type of person would be better suited. As I indicated, we have special formulas here for problem-solving courts. This is a quick process. It is actually on top of
your assessment process, it takes about five minutes to complete. Because it compliments your using a package of standardized assessments. One of the things that this
particular program does is that it recommends
different levels of care. Problem-solving courts are in Level A, which are for people with high severity of substance use disorders. But we also recognize that sometimes, you bring people into
a problem-solving court that has criminal thinking
with a secondary issue of slightly less severe
substance abuse disorders. And that just means that the
programming needs to change for that particular individual. And that’s part of one of
the things that we look at. Another part of the RNR simulation tool is the ability to actually look at what’s going on
within your intervention. As I said before, we
are able to do this both for the therapeutic component, but also for the
problem-solving component. So it, when you’re, and this a one hour, approximately one hour timeline survey that your treatment
administrators and, or your court administrator would complete or sometimes both of them would need to complete it. It basically ranks the
program in terms of the use of the RNR principle and
then it gives a cheat sheet on how to make improvements
in your problem-solving court. So for example, in this particular court, implementation is slightly,
is modest in this court and it would actually help
to define those components of implementation that
would enhance outcomes. Another part of the program
tool is it will rank your program compared to other programs on different dimensions
that are very important in assessing the quality of services. So we know that we
struggle in this country you know, with making
sure that we can provide appropriate quality services for clients. And this is one way of programs being able to do a quick assessment, actually learn from them,
about their own program and then gives you, like I
said, this cheat sheet of ideas. We’ve recently just added
some new implementation scales to look at how quality assurance, the use of rewards and sanctions and the use of clinical standards in substance abuse treatment programs, including those that work
with problem-solving courts. And finally, the toolkit
does the staff analysis. Sort of my favorite part here. It allows you to look at your population and to compare your population against the types of services that
they would most benefit from. And all of this is
available on our website and if you have any questions, feel free to contact me or my team. So overall, what’s important here in the problem-solving courts, is that we deal with making sure that we’re tailoring
things to the individual, that we’re providing for systems issues and making sure that
treatment and services are integrated within the court
structure, not secondary to. And I know with medications
and assisted treatments, this is a major challenge
because often times the providers are subcontractors. But we really need to
begin to really think about some of these
systems issues to make sure that the clients are getting
the most integrated care. And then our biggest challenge is providing high quality programs, both in terms of the nature
of the treatment courts, but also in terms of the nature
of the treatment services and medical and any medications
so that all of these pieces together can be used to make sure that we have the strongest
problem-solving courts possible. So beyond our simulation
tool is just the toolkit to really help facilitate
some of the decisions of problem-solving courts
but these decisions have to do with who’s eligible, what types of services do you offer and what is the quality of those services and then are you providing
the full range of services for the client in your
problem-solving court? So with that, I’m going to
turn this presentation over to my colleague, Dough Marlowe,
and Doug, it’s all yours. – [Doug] Yeah, thanks, Faye. That was an excellent presentation. I’m not gonna repeat any
of the basic concepts of Risk-Need-Responsivity
that Faye mentioned and their application of public health. I think she did an
extraordinary job with that. Drug courts integrate the treatment and the criminal justice field. And so we tend to think
about RNR in clinical terms and I will often use medical analogies to talk about RNR because medicine is a very well established,
mature profession. They have standards, they have guidelines, they have ethical codes,
they have procedures and that’s something that we
really should be emulating. So imagine that you haven’t
been feeling well for some time. You’ve been sick, you’ve
been very concerned and you go to your doctor. And you tell your doctor,
I don’t feel well, I haven’t been feeling well for some time, I’m very concerned, please help me. And your physician says, no problem, take this medication it
will fix you right up. And you say, now wait a minute doctor, I’ve been to enough trainings to know that it needs to be an
evidence-based treatment. Is this an evidence-based medication? The physician says,
absolutely, it’s been proven in multiple trials to improve
outcomes, approved by the FDA, it is a evidence-based treatment,
take it, it will help you. That physician has just
committed malpractice. And in fact, that physician
is committing malpractice per se which means on it’s face. Because that physician
didn’t do two things that a physician is required
to do before treating. Number one, diagnose the patient. You are not allowed to
treat without a diagnosis. And number two, prognose the patient. Does this patient have
complicating factors that makes it less
likely they will respond to a low dose front-lying treatment and therefore I need to
treat them more aggressively with a more potent intervention. Now you might wonder, well
why don’t we just treat everybody with our most potent treatments? And the reason is because
treatments all have side effects and the more potent the treatment, the more serious the side effects. And so if somebody has a good prognosis for a front-lying treatment,
it would be malpractice to treat them with a
very intensive treatment because you are risking greater side effects with no therapeutic value. What the medical system
refers to as diagnosis and prognosis, the
criminal justice system, the treatment system
refers to as risk and need. Risk is essentially prognosis, need is diagnosis and so we
know from the risk principles, Dr. Taxman said, if you
provide too much intervention, too much supervision based
on somebody’s risk level, not only do you not make them better, you actually make them worse by getting the side effects of a potent intervention. On the other hand, if you
respond, treat somebody in a too weak level with
insufficient supervision, with insufficient services,
the chronic disease process just continues and gets worse and worse and in fact, people get, they
actually build a resistance to treatment if you give
people low-dose treatment, if you give people half
the dosage of medication they’re supposed to take, not
only do they not get better but they build a resistance
to the medication. So if later on, if they
take the appropriate dose, they actually get worse
and so the reason we don’t over-supervise or under-supervise
is because we are risking side effects or, and
undermining the intervention. Need, if risk is the prognosis,
then need is the diagnosis, or the functional impairment,
the what to treat. And so if you give
somebody too much treatment based on their clinical needs, not only do they not get
better, they get worse. And if you give somebody
too little treatment, not only do they not get
better, they get worse. We have actually found
through painful experience that if you give somebody
treatments that they don’t need or more treatment than they need, you actually make their disorder worse. And part of the reason
for that is that risk, like need, I neglected to
mention this, risk and need, to borrow from medical
analogy, are highly contagious. If you take a risk, a
group of high-risk people, you put them together in a
group of low-risk people, you will get a group of high-risk people. The high-risk people
will raise the risk level of the low-risk people
and the low-risk people will have no impact whatsoever on the risk level of the high-risk people. It would be like taking
somebody that has a broken leg and putting them on the
tuberculosis ward of a hospital. Now they have a broken
leg and tuberculosis and that would be malpractice
in the medical field. Now responsivity which
is the how to treat, the analogy is to case planning, it’s to creating a treatment
plan, a diagnostic plan. And what we have found
is that treating needs in the wrong order makes outcomes worse. So if you give someone treatment they don’t need, they get worse. If you don’t give somebody treatment they do need, they get worse. And if you treat their
problems in an inefficient, ineffective order, it actually gets worse. So the point here, I think from RNR, is that there are more ways to do it wrong than there are to do it right, and that’s the way physicians are trained. They’re trained from day
one, diagnosis, prognosis tells you how aggressively to treat, how, you know, what interventions to use and then you create a care plan that sets out what you’re gonna do first. First we’re gonna do surgery,
then we’re gonna do radiation, then we’re gonna do chemo,
whatever, has to be in the right order because if it’s
not in the right order, the case will not get better
and indeed might get worse. So most or many treatment
courts in the country have adopted what is
called the quadrant model and Judge Davis will be
speaking about this shortly, the quadrant model says
that if the appropriate interventions for people
are based on diagnosis and prognosis, then broadly speaking, you have four types of
people speaking very broadly. You have people who have a
high-risk for treatment failure, or a poor prognosis, and
they have a high-need. So somebody with a severe addiction who also has a long history
of treatment failures. Somebody who has a severe addiction but also has anti-social
personality disorder and their criminal associate,
everyone they hang out with are themselves engaged
in criminal activity and they have an early
onset of criminal conduct and multiple prior convictions. So they really need treatment
and they have a poorer prognosis to succeed in
a standard intervention. For those people that we
call high-risk, high-need, they need four legs to this stool. If any one of these legs is
missing, the case must fail. The first leg is supervision
and among the different things that we include in
supervision, there are many, would be what we call status reviews. So status review for a
behavioral psychologist is when somebody meets
with the participant, somebody who has the power and authority to do something meaningful to them. So, if I have the power to
give you a sanction you really don’t want, or to give you a
reward that you really do want, if I have that power, then it would count as a supervisory meeting
as a status review. And so people who are
high-risk, high-need, need to have frequent status reviews. And what our research says
is approximately to start, at least every two weeks or more often, they need to come to court, appear before the judge for reviews. Now we’ve, we suspect that for people on probation it would be equivalent if they were meeting
with probation officers. Most of our work has been
in the drug court context. Point here is that supervision, treatment does not count as supervision. You can’t send people
to a treatment program and say okay, they’re
gonna be supervised there. Because treatment professionals
do not have the authority, the training, the
expertise, the inclination to impose substantial
rewards and sanctions. It’s not their job. In addition, and supervision
would also include drug testing, it would include
community surveillance, it might include GPS monitoring devices, it means knowing what the person’s doing and responding if they are
not showing up at treatment or committing other infractions. Treatment critically
important for this population. Dr. Taxman discussed some
of the aspects of treatment. It must include
medication-assisted treatment, where indicated, it should
behavioral and cognitive behavioral in orientation,
it should be manualized structured, it needs to be
evidence-based treatment. Then there’s something we
call pro-social habilitation. Many of you may be
familiar with this using interventions like thinking for a change or moral reconation therapy, MRT, or a reasoning and rehabilitation. These are interventions
that focus on the sometimes criminal thinking, what
the 12-step community would call stinking thinking,
tendency to see oneself as the victim rather than the perpetrator. Not to think before one
engages in impulsive behavior. Not to consider the
consequences of your behavior. So in addition to treating
the clinical disorder, the addiction, mental
illness, you need to address this dysfunctional thought
patterns in this population. And then, adaptive habilitation
is the job training. The you know, literacy
courses, learning to open a bank account, parenting skills, those kinds of interventions
that help people to function effectively in the community. And, I’ll get to this a little
more in a bit, but the order of these interventions
is critically important. That if you start as many programs do, they start somebody’s on probation, and they are told, you know,
the first weeks of probation, they need to get a job or they
need to re-enroll in classes or they need to, you know,
get a driver’s license or whatever, you’re
moving onto these adaptive habilitation components
when you haven’t dealt with all of these other issues in their lives that are more pressing. So that is the high-risk, high-need group. If any of those elements are
missing, the case must fail, and that is your treatment court group. That is what drug courts were created for. People who are high-risk
for treatment failure, high-need for substance abuse treatment, very often have, you
know, very anti-social lifestyles and very poor job skills, they need the whole
gambit of interventions. Upper right quadrant,
people who are low-risk but high-need are individuals
who have, may have severe addictions but they don’t
have those risk factors, those poor prognostic indicators. We are actually seeing more
and more of these low-risk high-needs people in drug courts as a result of a few things. One is the opioid epidemic,
where a lot of people are being introduced to and
becoming addicted late in life. People who had an injury in
their 20s, 30s, 40s, 50s, become addicted to these
opioid medications. They were high-functioning
before that so they don’t have these risk factors
for treatment failure but they have very severe addictions. For these people, they really, you don’t need and should not engage in these very intensive
supervisory interventions, they actually get worse if you make them come to probation or to court and spend lots of time with
the other high-risk people. What they need is
pro-social rehabilitation and adaptive rehabilitation, you’re really returning them to a previous level of functioning that
was lost in many cases. And these are the people
that should be diverted out of the justice system into treatment, with the justice system making
sure they go to treatment. So probation is saying to
the treatment providers, make sure they’re there,
if he’s not showing up to treatment, let me
know and I’ll intervene. But treatment is where the magic is. Where they, it’s the special
sauce for this population. Lower left quadrant
individuals who are high-risk but low-need, they don’t
have the severe addictions, mental illness and other things, but they have risk factors for failure in supervision and for recidivism, very often they may have
anti-social personality disorder, they may have gang affiliations, they may have multiple
failures on probation before, long criminal records,
but they do not need and should not have
substance use treatment. If you’re sending these
high-risk, low-need people to programs like drug
court, and there are many of them in drug courts, when
they don’t need drug treatment and the whole basis of the
intervention is drug treatment, you are mismatching and when
you give treatment to people who don’t need it, you make them worse. So these people need the
intensive supervision, they will need the criminal thinking, pro-social habilitation,
job training interventions and examples of programs that
tend to be more effective for those are ISP programs
when they include intensive supervised pronation
programs when they include the cognitive behavioral counseling interventions that Dr. Taxman mentioned. Hope, a Hawaii Opportunity
Probation with Enforcement, which is a sort of a court-supervised probation implemented, close supervision, contingent consequences if
people aren’t doing well. They do not need and should
not be in drug court. The lower right quadrant people who have neither of these things, the high-risk nor the high-need. So what you’ve got in trouble
but they don’t have a serious addiction, they have a
good chance of you know, of learning their lesson
and not moving forward, these are the people who should not be in the criminal justice system at all. These are the people
who should be diverted and even the new term now is deflected, so that they’re not even arrested, they’re deflected even
if the police encounter, these are the people best
suited for a full deflection. I’m not saying that you couldn’t
also do a law enforcement diversion for the other cases,
but they would need services. Whereas these are the
individuals that we could put in a diversion program, what
many probation departments will call banked probation where they just have to let their probation officer know if they’re, you know, if
they change jobs or move, but other than that, they don’t need to be very regularly involved
in probation and the like. Specific responsivity, I’m
gonna move on it right after this, that we talked about the importance of the order and timing of intervention. And Dr. Taxman used a
term of stability factors, we use the term responsivity needs, I think they’re very, very similar. Responsivity needs are the needs that interfere with rehabilitation. The things that if you don’t
address them right away, you can’t get to anything else. If someone’s homeless, there’s no point in talking about their criminal thinking. If someone’s homeless,
there’s no important, there’s no value in talking
about their substance use if somebody’s from severe mental illness. You have to stabilize the case
so that they can then respond to the treatment focusing
on their criminogenic needs and the big criminogenic needs, as Dr. Taxman said, are criminal thinking, hanging out with a delinquent peer group, addiction, drug use,
these are the, you know, a family dysfunction, these are the major criminogenic drive, drivers of crime. After those have been stabilized, then you move on to what
we call maintenance needs. These are the needs
that don’t cause crime, but if you don’t address them, the case falls apart as soon
as they leave your program. So this is where employment comes in. Where, you know, getting your GED, where opening bank accounts, you know, learning how to adapt, those
are your adaptive skills. Humanitarian needs are other
needs that cause distress. If, you know, of course if
they’re life threatening, we’re gonna deal with them right away, but if someone has dental
problems or other things, we’re certainly gonna refer
them for those services. But, you can fix their dental problems, it’s not gonna have any effect
on their criminal activity, it’s just you should do it anyway. And then we get to what we call the restorative justice needs, which this is the restitution to victims, community service, giving back,
and assuming a law-enforced, a law abiding stance in society. Many programs require
participants to get a job and start paying restitution
right from the beginning when those should be at the
end of the intervention, after you have addressed
their mental health issues, their homelessness, their criminal, their addiction and the like. Since we don’t often have people long enough to address all their needs, that’s where your continuing
care plan comes in. If the person only gets
through maybe the third level and they’re dealing
with employment skills, that’s what you need
to set up to make sure they continue in this correct order of intervention after they leave your treatment court or
probation or the like. The important thing here is
that each phase advancement, each time you move through those numbers, increases the odds
they’ll pass the next one. So if you get someone stabilize
their responsivity needs, you increase the chances you will be able to stabilize their criminogenic needs. Stabilize their criminogenic needs, you increase the odds that
you will be able to address effectively their maintenance needs. The opposite is also true. If you skip a need, or you fail to address it adequately and you try to move on, the odds of them succeeding
in the next step go down. And that is why the order of intervention requires considerably more thought than just throwing the whole kitchen sink of interventions or whatever interventions happen to be available to a program, just making them do what you say, this is our menu of services, that is not the correct
way to manage these cases. In conclusion, it is
impossible to do evidence-based practices unless you have assessed risk and need prior to disposition. For example, as part of a PSI, just as it would be malpractice for a physician to treat without
a diagnosis or prognosis. I would argue that it is
malpractice for any of us to do anything to people
who are under our control, supervision, authority,
when we don’t even know what we should be intervening on. That acting without a risk-need assessment is essentially malpractice. Of course you have to give what people, what’s called use immunity which means any information they
give you in the course of the evaluation can’t
be used to substantiate criminal charges or
augment their sentences exclusively for setting
their treatment plan, using valid, reliable and culturally unbiased instruments,
of course is critical. I would make the argument though, I know there’s a big
backlash out there right now about risk-needs
assessments may exacerbate racial and ethnic disparities, everything that we know, we
don’t know a tremendous amount, but every study that’s
looked at it has found that risk, that when you use
risk and need assessments, racial and ethnic disparities
go down, they don’t go up, because you’re following
evidence-based practices instead of personal biases and beliefs which tend to lead us in
very discriminatory ways. This is a segue to Judge
Davis that therefore, it is important in treatment courts, if you are going to treat
people who are not all high-risk, high-need, you
must have separate tracks to avoid mixing up your
populations and ideally you should automate the if-then decisions, you know, if the person’s high-risk, high-need, then they go in this track and if they have these responsivity needs, they’re dealt with first. That kind of information can be and should be kind of systematized in your policies and procedures manual so that your program gets used to setting
up care plans that way. And with that, I’m going to pass it on to my distinguished colleague,
Judge Davis, thank you. – [Peggy] Well thank
you and hello everyone. Thank you Dr. Taxman and
thank you Dr. Marlowe. You know, for those of us who
have our boots on the ground, these concepts wrapped up beautifully and so we have this great
package in front of us regarding risks and needs and
making sure that the people that we deal with actually
become productive citizens. And then we turn and go to court and it’s a lot more difficult
to implement than it appeared in this 40 minute discussion
as our host to know. So what we did in Greene County, was we looked at this concept and we looked at the risk-need assessment and we were required to do
that by the Supreme Court. And then most of us thought, well, if we do that, what do we do next? And so I’d like to explain to
you kind of what our treatment court model looked like when began, when we began to actually
use the risk-need assessment and divide out our participants
according to their need. And so I’m excited to share
with you what we have. So, let’s see if we can go there. In 2013, we implemented
the four-track model, or the four-quadrant model
in our treatment court. We were not able to actually
put people out of the system because we’re a post-flee for a large part and so we just kept a lot of our folks, but we thought this would be a way, quite frankly, to reduce our cost. But what we found was it also increased our outcomes dramatically. And the tool we used was
the Risk Needs Triage, which is the RANT and we
would administer the RANT prior to people coming into
the treatment court program and then we would look at
what we had once we did that. And so our objective was
to match our risk need through screening and assessment, match our supervision level to the risk and then conduct a clinical assessment and match the treatment
services or clinical services according to the need that
we saw in front of us. A lot of us who have done criminal justice for a long time on the ground,
have this tendency to think that if a little bit is
good, more is better. I remember judges would say to me, well I know if an individual
was caught with drugs in their purse, that they
had a substance use disorder and we’re all guilty thinking
that so we would throw a ton of services at people thinking
we were doing everybody a favor and as you’ll see on
some of the data that we have, I think we actually made people worse. So we learned that the
things that Dr. Taxman and Dr. Marlowe are
talking about are exactly the things that happen when
we employ these practices, either correctly or incorrectly. So the first thing we do,
I’m not going to spend a lot of time on this
because we’ve already talked about it but remember,
if the risk is high, we match our services to the
risk, our supervision services. If the need is high,
we match our treatment or clinical support to the need level. So, track one, or quadrant one, was the high-risk, high-need individual. This is your traditional drug court. I’m not going to spend
a lot of time on this. This was what our drug court looked like. But what you will note and you will see that it is everything that most of us do who try to follow best
practices with drug court. Particularly, there’s substance use treatment included in this track. There’s noncompliance calendars, there’s status hearings with court, there’s that ability to
respond to their behaviors immediately and we also included
cognitive behavior therapy in order to address those thinking errors. So this is the whole ball of wax. This is everything that we want to see and this is where we put
everybody for a long time, in a program regardless of risk-needs. So we divided it out
and those who screened high-risk, high-need and
screened with the clinical assessment to have the need for treatment, got the traditional drug
court, which is track one. And then track two was
the low-risk, high-need. And so track two was that
population as Dr. Marlowe talked about that you know,
may be an older population, and that’s indeed what we saw. Who may have gotten
involved in the opioid issue with an injury and then found themselves dealing with a substance use disorder. We realized, we don’t need to supervise them at a high level but we did need to give them clinical support
and substance use treatment. And so here’s what the
actual program looked like. If you’ll notice, on
the first bullet point, the court status hearings were only once for three months or as needed. So if somebody came into
that program and had a need to see the judge earlier,
we would certainly see them. I did touch base with them occasionally and found that to be effective in reinforcing that we were there. We had a program that they could actually complete and know that they finished. Had a lot of positive reinforcements and treatment, medication,
the things that the individual needed but it was not
focused on supervision, because if their truly track two, we found they didn’t need
that supervision piece, they didn’t need to come to court. But they certainly needed treatment. Then track three. This track surprised me a little bit. This is the one that
is high-risk, low-need and so these individuals have
the high criminal history, they have a criminal behavior and a lot of criminogenic needs, however they did not assess as having a substance use disorder. And so the absence of this program, if you’ll note on the next slide, looks very, very much like
our traditional drug court. However, one thing is missing and that is substance use treatment. We did look at where needs were for folks. Sometimes there were PTSD
issues or trauma kind of based services that these individuals need, but they certainly didn’t
need substance use treatment. And so it was very similar to what you see in the treatment court,
but we did not send them to our treatment providers in order to mix them with the population that we’ve seen prior to this discussion. Track four, that low-risk,
low-need individual. I always think of these
as the college student that Grandma gave a Xanax at test time and said, take it, it’s good for you, and of course they get caught
and they pick up a felony. But these young people generally
are not going to come back and so we give a very
minimal supervision piece and we actually looked at
prevention or education. So you’ll see our track four, did not see these individuals very often. And again, saw them as needed. There were some issues
that we needed to address. If you look at the pieces
in regard to responses, we had some education classes
and then one of the things that we did and included in addition to the education classes, is
we did do an individual session or more, based on need,
looking at what kinds of things drove this behavior. May not need to be a big individual, or long-term individual counseling session but it helped identify
those particular issues that were driving behavior and often times intervene with a slide downhill. We did do some drug testing, as you know, we wanted to make sure
that our assessments and our screenings were accurate and that we were able to identify and so we would test
periodically for a while to see really what we were looking at. Not as much supervision, again,
and so we had that track. What we learned was
that these adjustments, or these screening tools, are a snapshot of the individual’s needs. The reason that we continue
to keep our fingers on folks for a bit was occasionally, we found that through, you know, people who are treatment savvy or people who are savvy with
the risk needs assessment, we really didn’t get an accurate picture. It did not happen very often. It was a unique experience
and it rarely happened but we did have the ability
to, if we saw behaviors, or we saw needs that we thought were more, we would again, assess,
look at what we had and had a system where by
we could transfer people from one track to the other
based on what our assessments told us after we got to
know our individuals. So, here’s the lessons that we learned. We learned that you shouldn’t
mix risk-needs populations, and we learned that through our data. But we also learned it
through focus groups that we’re going to talk about. And a couple of things
also that we learned, and it’s a little difficult
sometimes for judges who have their feet on the ground and so many other responsibilities, but the court docket shouldn’t be niched. You know, when we talk
about changing behaviors, it’s important that people understand why we’re responding the way we respond. And the danger in mixing
those court dockets is people don’t understand
always why you got a different response to
somebody who does not have a substance use disorder and decides to use you know, opiates over the weekend, that’s gonna be a different
response than somebody who’s in the high-risk,
high-need population and early on test positive for opiates. That would be in the last example. That would be a treatment response, and in the first example it
would be a more behavioral response and a stricter sanction. If the dockets are combined,
my suggestion is that you bring them in, you know, even
15 or 30 minutes apart and be very, very clear in court why we are doing different things for different folks so
that that explanation is there remembering that
courtroom as theater. This was one that is a challenge because you know, we
have these great ideas and then we go back and
we try to implement it, but our treatment providers don’t work. So this process that looks fairly simple took about a year to implement because we had to go back and educate treatment on our expectations. And treatment, a lot of
the times we would find, would mix people in
groups on risk-need level, not understanding exactly what
we were trying to accomplish. So one of the things we need to be real clear with when we’re talking about how to do this is we
didn’t want groups mixed. We didn’t want to have
the same different people in different groups even if the
topic at group was the same. And so in small programs,
it may be that you want to consider just using
individualized treatment for your different populations. Supervision, it was really
preferable to have POs, or supervising officers, have a case load specific to the risk-need level. It kept the POs focused. People talk, as you well know, who are in this criminal justice community and it kept them focused on the PO that they had and they didn’t say, well, this PO was nicer to Joe than he was to Sue, not understanding that there were different
risk-needs level. And then our officers need to be educated about the difference
in responding to people based on their risk-need levels and proximal and distal behaviors so we are consistent
in our court responses and our responses in regard
to treatment services. So, we need to take time to plan. We have to educate our team members, we have to educate treatment,
we have to get everybody on board on this concept and then sit down and actually look what
the program looks like. Look what how it works from
day to day in the operation, talking again, referring
back to the group sessions, you know, if you don’t have
enough people in a particular risk-need level to hold a
group, then it’s better, it’s probably better to
hold individual sessions. We looked at supervision expectations, again, the officers looked
at what they can expect, what behaviors they’re
going to respond to, have realistic expectations
about what success looks like at each phase and then
identify our treatment. Substance use treatment for the track one, not substance use treatment
for the third, the track three, and then you know, no
treatment for the track four, and then track two, again,
you know, we need some pretty intense treatment but
not a lot of supervision. We need to revisit these expectations. Again, once you’re used
to doing business one way when you start changing
things and you have people really changing their approach to things, it’s important to revisit
with your team members and say, how’s it going,
what are we doing, and keep that expectation
tight as we adjust to this change and the way we do business. And so, we were really fortunate
in the State of Missouri in that we wrote for a grant with SAMHSA, and it began, this grant
study began in 2014, we were in Missouri, accorded
this grant to do an evaluation on the four-track model
and the two jurisdictions in Missouri who were the research sites was Jackson County, Kansas City, Missouri and then Greene County,
Springfield, Missouri. And so we have this evaluation back, it was completed in September,
2018, and the evaluation was conducted by NPC Research. Dr. Shannon Carey worked
closely with our court. And I’d like to share some of the results with you on what we learned
through this process. Let’s see, let’s go back. (clicking) Alright, the first thing we learned that I thought was significant, was we had higher graduation rates. And if you look at this, it’s interesting. Pre-four-track models. All of our drug court folks
who went through drug court prior to implementing
the four-track model. We had a 45% graduation
rate and we had always taken a good dose of high-risk,
high-need participants. After the four-track model
and tracking out three years on this, our graduation
rates went up to 68%. If you look at Dr. Carey’s
work on this evaluation, what she noted at the time was that the national average was 57%. And so we not only were able
to exceed our graduation rates or improve them by over 20 points, but we were able to improve them over the national average by 11 points. And as we know, graduation
rates are a good indicator of how individuals are going to perform after the drug court program. This is a slide that shows
you what it looked like after people graduated from the program or the other comparison groups and what we note is that we
had less reincarcerations. So if I can kind of explain this to you. The red or kind of dark brown bar is a comparison group of
individuals who the cases would have been accepted into drug court but did not come into drug
court for one reason or another. And then the light tan bar are individuals who were in drug court and completed the program prior to
implementing this program. The blue are our post
four-track comparison, so these are the
individuals who were placed in the program according
to their risk need. And then the, oh no, that’s
the comparison group, so they were again, those
individuals post four-track, I’m sorry, who would’ve
come into drug court but did not for one reason or another. And then the light blue
track are those people who completed drug court
successfully after, and went through drug court
on that four-track model. So if you look at this,
the first year out, the pre-four-track comparison group had a 28% reincarceration rate. And what I think is interesting, sometimes evaluations
are painful to look at. Our pre-four-track drug court
actually performed worse. And you know, I think
the takeaway from this, and it will be interesting to see what Dr. Marlowe has to say in a minute, but the takeaway from this
is, this really shows me, if you are not treating people
according to their risk-need and you’re not giving them what they need, you make them worse,
and this tells us that. But if you look at the light blue, we really improved outcomes
to a significant drop. A 30% compared to a 39%
on our comparison models. And then look two years
out, again, 36% less than the other comparison
groups and three years out, 36%. Significantly less than
the comparison groups. And our data got better,
our people did better the further out we went,
they consistently stayed where we wanted them to be
which is in the community and performing as law abiding citizens. This is reductions in recidivism, those cases that came
back into the system. Either arrest for felonies
or picked up a new charge. And what again we see is
very, very interesting. Same bars, same designations,
but if you look, again, that light tan bar, which charts our pre-drug court people, first year out, we really didn’t have a
lot of bragging rights. Again, I think this tells us
that when we’re mixing folks, we’re not helping em’. But if you look at the light blue bar and our comparison, you’ll
see that we had significant reductions in recidivism. We had less property and
(audio cuts out) crimes because we take
a host of individuals in our court, we had 50% approximately less drug related rearrests, drug crimes. And three years out, you can see that we’ve continued to
maintain those outcomes. I’m gonna do this real, real quickly, but for those of us
who are not evaluators, these focus groups, I
thought said beautifully, what we’re seeing and that
is the quadrant one people, when we did focus
groups, complained a lot, but they also recognized that
the program saved their lives and they were willing
to call each other out. They also talked about probation burnout, whenever they were in programs
that continued forever. They’d give up because we’d
keep after them for so long that they just, that
feeling effect where we lose our ability to make a
significant change with people. On the track two people,
and that’s the people without a lot of criminogenic need. And the substance use disorder, they were appreciative of the services they had and they were more
supportive of each other. Track three, worked on criminal thinking and said they never really fit in with treatment court and treatment groups. And they told me that in court too. They had a lot of high collateral needs but they did very well. This was one of our best performing groups when we look at the
data and they did well, I think, because they didn’t have some of those responsivity
factors running against them, such as mental health disorders
and substance use disorder. And then the folks that kind
of dropped into our system for a host of reasons that
really don’t have those high criminogenic risk factors or needs, I thought it was interesting, they said they were scared of people in the court. This wasn’t where they felt like they belonged and they performed better. And so you can see some of
the comments that people had. People said, I like the different tracks, this person had a little
of experiences early on in our system and understood that it was different beforehand and so, said that they
didn’t have to spend all the time going to treatment and could work and be productive. This person, these people
talked about that again, we focused and they were able to focus on the issues that drove
them into the system. And then this is a quote
from Shannon Carey, at the end of her
evaluation where she said, it seems clear that using
risk-need and responsivity in a drug court setting
increases public safety, lowers criminal recidivism
and has a substantial cost savings to the taxpayer. And it was during that
evaluation that Dr. Carey was able to identify, that
was the saving of about $4,733 per participant per year, and if you look at the
average which we normally ran of 300 individuals per
year, that was $473,000 in tax savings per year,
running out and increased over seven million in over five years. And so we make a big
difference in our community. I want to commend all of these researchers who said, trust us, do this. And then I’m here as a
boots on the brown person to tell you, I’m excited,
this apparently works and makes a tremendous difference in the effectiveness of our programs. And with that I’ll turn it back to our, what, our lead person? – [Melissa] Alright, thank
you so much Judge Davis. And thank you to all of our presenters. We, for just presented a lot
of really great information and so now we are gonna take some time to go through your questions
and some of you may have seen something just
pop up on your screen, the box is entitled File Transfer, so we do have a couple of
handouts that we are sharing that will hopefully
help you as you proceed and try to implement
some of this information. The first document is an RNR,
kind of a matrix of tools that are commonly used in
applying RNR at the practice, in practice at the drug court setting. And then we also have a fact sheet on RNR. So both of those are available. You can click on them and download them directly to your computer
for more information. And, so at this time, I’m just gonna go through the questions that are being submitted in the Q and A portal. Once again, this is to the
right side of the screen and we welcome you to
submit any other questions you may not, you may have. So starting off, and
this question, I will, I would say I think any of our
presenters can answer this. So there is, the person asked,
would you say a RANT report would target people with a
higher criminal thinking need over substance use disorder
if for no other reason because that person may be
more suitable for drug court? So any response to that question
in terms of what a person with a substance use disorder
may be more appropriate for, versus consideration of
higher criminal thinking needs. – [Doug] So this is Dough
Marlowe, can you hear me? – [Melissa] Yes. – [Doug] Am I, okay. So, yeah, I’m not
entirely sure I understand the question but let me take a stab at it. So, I think that when we look
at reentry court populations using tools like the RANT and other tools, we do find that a higher
proportion of them tend to fall in the two left quadrants. Either the high-high, you
know, the high-risk, low-needs. We do get a higher proportion
of those individuals. In terms of weather they
would be more suited for a traditional
treatment court as opposed to a reentry court that doesn’t include an emphasis on substance abuse treatment, that would really depend
clinically on the case. Some people make a mistake of thinking that because somebody’s been in custody for a substantial period of
time and they’re no longer, at least not currently suffering cravings or compulsion or withdrawal,
that they are therefore no longer addicted and
that’s not the case. As soon as their released,
if they had a preexisting addictive disorder, it’s
usually awakened quite rapidly. And so, if they went in
with an addictive disorder, then they would be high-risk, high-need and a reentry drug court would
certainly be appropriate. – [Peggy] This is Judge Davis. I agree with Dr. Marlowe. I would like to say that if
you have the opportunity, that population that
does not have a substance use disorder and you can
treat them in treatment court, they can do very well but don’t mix them. So I think there’s an
opportunity there for both, but it’s really a situation where you need two different kinds of
programs for those populations. So you need to decide which one, if you have limited resources,
you want to focus on. – [Melissa] Any other comments? – [Peggy] No. – [Melissa] Okay, alright
so the next question is also kind of on the
substance use issue, more specifically about DWI, OWI charges. I’m gonna try to read it to
you exactly how it’s written. Many OWI thirds, which is apparently you know, one of the higher levels of operating while intoxicated charges. So, many of OWI thirds and higher come with a lower risk and
moderate to high-need. She said, we use COMPAS,
problem is, this is not appreciated thus encouraging the lookout for a tool that will make the risk higher. I’m not sure I understand
the complete question but it seems that they’re
struggling with understanding how to address the needs of
people charged with OWI’s falling at lower risk but
moderate to high-needs. So any comments on that? – [Doug] This, again. – [Peggy] I’m sorry, Doug,
I was just going to add, is tell her that she’s exactly right on what we saw with DWI court and I want Dr. Marlowe to respond to this. And that is that traditional
risk needs assessments, I think underestimate or
underscore those folks considering the risks of dangerousness, but they don’t pick up as high-risk, high-need of a traditional assessment. And I think Dr. Marlowe is more adequately equipped to address this. – [Doug] Well, I would just
underscore what you just said. What a lot of studies have really shown is that risk tools, sort
of in the many respects, systematically under-assess risk. And what I mean by that is
that you get a very high false negative rate or a much
higher false negative rate. As somebody comes out as
low-risk on a, you know, a DUI individual comes
out low-risk on a tool, but in fact has a high recidivism rate. And so the tool’s missing the propensity for recidivism, a propensity
for treatment failure. And the reason for that
is because these tools were really originally
developed for popular, you know, that we developed
tools based on risk factors that number one, are highly
predictive and also need to be, they need to occur
with enough frequency that they can actually
differentiate populations. And the risk factors for treatment failure in a DUI population or OWI population, are, tend to be, they
overlap with those of a more traditional drug court or
offender type population. But they’re different
enough that your missing it ’cause you’re not
asking the right questions. And so I know that the
American Probation and Parole Association recently
developed an instrument, and I’m blanking on the names of it, drunk driving assessment or something like that, where they actually, you know, they specifically
validated a tool using the kinds of items that predict DUI
recidivism specifically. You know, so for example,
most risk tools the LSIR and the COMPAS and others,
generally don’t ask, what was your BAC, your
blood alcohol level at the time you were arrested? But that is highly predictive
of recidivism in a DUI population, so you want a
tool that asks that question. How many traffic violations,
speeding tickets, parking ticket violations,
these are things that are not particularly predictive and not, you know, that
they’re not necessary in a more traditional
criminal justice population where many of them don’t even have cars. But for a DUI or OWI population, those things are very predictive and so you need different tools. And so there are a few out
there now that are specific to that population and so
that, I think you really need to select a tool and try
it out on your population. – [Melissa] Thank you Dr. Marlowe. Any comments in response to that question? Alright, so the next
question kind of transitions a little bit more towards the… Practical challenges that
some of the drug courts face. So this person asked, we are
struggling with limitations on Medicaid coverage
for lengthy treatment. In fact even being able to
justify a full 12 months of substance use disorder treatment is very difficult, let
alone lengthier times. Any recommendations for working with Medicaid on this problem? – [Doug] Okay, this is Doug again. I might make a few recommendations. There are a number of
resources out there now. There are ones developed
by the Legal Action Center, the LAC, which you can download. There’s a SAMHSA resource
guide that I’ve been writing that’s federal, that
will be out very shortly. There’s the National Academy of Sciences, just came out with their report, literally in the last
month, all of which review how long medication-assisted
treatment should last. And the short answer, the
simple answer is that even to attempt or to talk about
it, even begin a tapering regimen in less than 18 to 24 months is almost always associated
with treatment failure. So if you are, so there is
no scientific basis anywhere for reducing any of
these medications in less than roughly a two year period. And that doesn’t mean you
should do it in two years, it just means that you
don’t even start thinking about it and introducing it into your care plan until at least 18 months out. And so, the, you know, the way to lobby for this if that’s the right,
if that’s the wrong word, but you can actually pull down some, you can actually download materials from the LAC website, where
they’re just literally sample letters that you can
sent to funding agencies and to jails and to
judges and other people who are engaged in what is clearly ineffective, substandard practice. And say, you know, the following organizations say don’t do this. And, you know, but that’s
the way to advocate for it. And I would definitely point
you to the, it’s the National Academy of Sciences, Engineering
and Mathematics, NASEM. Just came out in 2019, the
national report by the leading researchers in the, you know, the country. But the, you know the WHO, the World Health Organization has one. The Surgeon General, our Surgeon
General I think published one last year, all of
which says that, you know, that these are, that
these regiments must be, must be measured in years
and that anything less than that is incompetent care. – [Melissa] Do either
of our other presenters want to comment to this question? – [Peggy] I think, I don’t think I could improve on what Dr. Marlowe said. – [Melissa] Okay, alright,
so now transitioning to a question more about the tools. This person said, our
district courts struggle with the costs of these tools and most are currently using
the needs which doesn’t really meet this type of assessment. So apparently they’re struggling with having the right tools
due to the challenge of cost. So, any comments as to
how barriers due to cost of assessment tools and
how those can be overcome? – [Doug] At the risk of always being the one to open his mouth first, but I’m sort of known for
that, this is Doug again. So, there are highly
effective validated tools out there that don’t cost anything. You know the, certainly the
ones that are most studied out there do have costs associated with the level of service inventory, for example, and the
COMPAS and some others you know, have costs associated with them. But I think the question was
more around the clinical side of it, so there are instruments like the Addictions Severity Index, the Global Appraisal of Individual Needs, Texas Christian University
Drug Dependence, there’s a series of tools
that give you assessments of addiction, dependence and comorbid mental health and social service needs, that the instruments
themselves have no cost. They’re not copyrighted,
they’re, you know, they’re used all over the country. The issue though is
garbage in, garbage out. And so if your evaluators are not trained and competent, then it’s not worth doing. And so, somebody in your team needs to be trained on risk-need assessment. We sometimes use the word
clinical case managers for these people, we don’t
just say case manager, ’cause that’s a very generic
term and applies to anything but, so a clinical case
manager is gonna be somebody with some kind of clinical background. Usually social work or
psychology or counseling, who knows how to ask
the questions in a way that gets good quality
answers about, you know, Dr. Taxman gave you the taxonomy
of when use is compulsive as opposed to when it’s risky and being able to get a quality of that, of the compulsiveness and
the level of pathology. And that requires clinical training, so somebody in the team
needs to be trained. Preferably more than one
person, but at least one. We have found in drug courts that ideally there would be two people
on the drug court team. Assuming you were treating
a large number of people. If you have a drug court of
20 people, that’s one thing, but if you have 300
people, you’re gonna need at least two highly
trained, clinically trained, case management types who know
how to do these assessments. And they can get their training
through something called TASC, T-A-S-C, Treatment
Accountability for Safer Communities, I think it stands for. Where they’re trained how to do that. But the instruments themselves, I mean, you know, they’re, you
know some of them cost money, I’m not saying anything
negative about their cost, whether that, you know, they cost money, but there are ones that are free. – [Melissa] Alright, thank you. And I think this question
might be more for Judge Davis, but the other panelists feel
free to also contribute. This person asked, are
there due process issues when you place a participant
to a high-risk, high-need track when that track is longer
versus a shorter track? Who makes that final decision? Is there an appeal process? – [Peggy] You know, that’s
a really good question, especially considering all the
law work getting in treatment courts in regard to constitutional issues and I have to tell you, that
we’ve not experienced that. One of the ways to
avoid that is to conduct that risk-need assessment
prior to the individual actually making a decision
to enter the court. And that’s the process we followed. So if somebody for example,
is referred to the court, then the risk-need assessment
would have been completed and the score, and it
just gives you a score, would be related to the defense attorney and the prosecutor’s office
and then they would decide. Knowing what the program
was going to look like for that individual, they
would decide whether or not to accept that offer and come
in to the treatment court. So they knew before, the
individual knew before they ever signed the
contracts for treatment court what their program was going
to look like with the caveat that if the risk-need
assessment was inaccurate, you know, we had the authority through probation revocation
hearings or you know, those kinds of things,
to make adjustments. I did not have anybody ever,
over the what, almost eight years now, I didn’t have
anybody ever raise that issue. You know, we make conditions
of probation all the time for folks based on the
cases and the information that we have in front of us
and that’s what this does, is tell us what is effective in regard to our conditions of probation. – Alright, anyone else,
– I would just add to, I’m sorry, go ahead. – [Melissa] No, I was just asking if anyone else wanted to comment. (chuckling)
– I would just, this is Doug, I would just, I would just
add that the governing constitutional test is
a rational basis test. – Yes.
– As everybody knows, there has to be a, so that
the conditions of supervision must be reasonably, rationally
related to the person’s crime, likelihood of recidivism
and rehabilitation needs. And so, you’re more likely to find, to have your conditions struck, when you don’t do a risk-needs assessment and you don’t match
the conditions to that. When everybody in my drug court
must get the same treatment. When I just have a one size fits all, that’s more likely to be unconstitutional than having a tracking
approach like Judge Davis does, where you are by definition,
matching the supervision and treatment conditions to the person’s rehabilitation needs and
risks for recidivism. So I actually think that most
drug courts that are violating the constitution are doing
so because they’re not doing what Judge Davis is doing. – [Melissa] Alright, and
this may be our last question depending on how long the
response is, but this person asked, any lessons learned on
communication and coordination between the treatment court
providers and probation? For example, should providers
or probation officers meet regularly to
coordinate care, how often, and what kind of things should providers communicate to probation
officers and vice versa? I know that’s a pretty in-depth question, but maybe just the high-level response would suffice from Judge Davis or anyone else who wants
to speak to this question. – [Peggy] I’ll speak from
just the boots on the ground position and then Dr.
Marlowe can jump in since, you know, he’s got the science behind us. But, you know, they, the
individuals, the probation officer and treatment should be
speaking all the time or anytime there’s a change or you know, an issue that arises that
may have some implications with the change and what
the treatment protocol looks like or the supervision needs. So they need to be speaking to each other. And that’s why when I talked
about lessons learned, I went back and said that
you really need to educate treatment and your probation
officers before you institute this model so that they
understand between them exactly what expectations should be
asked of this individual. You know, where that individual should be at any given point in time. If somebody’s in a early
phase in treatment court and they have a significant
or severe to moderate substance use disorder,
their performance is going to be different than somebody
who has the high-risk needs but not a substance use disorder. And the best example I
can think of is if we get a positive drug screen or we get a youth. And then treatment and
probation needs to be talking. But the response with the
substance use disorder early on is going to be something
we probably expect, so they need to be talking
about how the treatment is going to respond to that and probation. Whereas in the model
where they’re high-risk and do not have a substance use disorder, you know, then that’s a behavior the individual has control over. And it’s really important to understand, those individuals will use,
but just because you catch em’ on a drug screen doesn’t mean that they have a substance use disorder. It’s a behavior and so that
response would be different and that’s why it’s so important
to keep these populations separate but then need to be talking. And then the court needs to be involved. And one of the things that I
see increasingly and we did, were noncompliance dockets so
that we were able to respond within a day or so of
these kinds of behaviors, so the individual knew we
were talking all the time. And so those kinds of issues, the court and the probation office needs to know. As to the details about
some sexual assault that’s created trauma, you know, none of us on the legal side I think, need to know the details,
but we need to know that that’s there because
it affects the individual’s ability to progress through
the program and it, and forms our opinions as to what success
in each phase looks like. And I’ll turn it over to Dr. Marlowe. He probably can run with
the science on that. – [Doug] No, I think in the issue of time, what I would do is
recommend that the person asking the question that if
you download from our website, the Adult Drug Court
Best Practice Standards, volume two of the standards
has an entire standard dedicated to the multidisciplinary team so the communication frequency, what data elements should be shared, that includes probation and treatment. If it’s in a treatment court context, this is directly on point if the question is coming from somebody working in a probation or other type of context. I think that the general, the
principles would be the same and all the research behind
why it is important to meet, how frequently and that
kind of thing is there. – [Melissa] Alright, any other comments in response to that question? Alright, and just one
last very quick question. Judge Davis, I believe someone
was asking for clarification that the different phases
used in the program that you shared about
were of different lengths. Is that correct? – [Peggy] Yes. Well, yeah.
– Okay. – [Peggy] The individuals,
we do the much shorter treatment court phase for
individuals who were low-risk, low-need, you know, so it
was based on their need. The, so, yes, they were shorter. – [Melissa] Alright, okay. So, there are a few other
questions that we’ve not had time to get to and where we are able, we may follow up with the
presenters to get further questions but I also want
to highlight everyone to watch out for our third
RNR webinar announcement that will be coming later this summer. So we will have a third
presentation on RNR and that will focus more on the reentry and community questions, settings, so please be on the look for that. You, the best way to keep up to date about our work and the
information on webinars coming out of the GAINS
Center is to sign up for our listserv and we
have the, a link, a URL for you to enter into your computer and you can sign up through this link. It is case-sensitive, so please do enter it in exactly as you see it. And once you sign up for our listserv, you’ll get the slides for this
webinar, once they are ready. You’ll also get a notification
when this recording is available and you’ll
receive our monthly newsletters and other notifications
regarding our upcoming webinars. And if you have any other information, or requests for information or questions, please do not hesitate to
reach out either to SAMHSA, the information is on the screen, as well as the GAINS Center. So we have our website and
direct telephone number listed. If there are any further questions that you would like to ask or any issues you’d like to troubleshoot
with the GAINS staff, please don’t hesitate to reach out to us. And we are here available
to answer questions. And with that, I just want
to thank our presenters, thank you so much for presenting
this helpful information and I think from the questions, you are seeing how much interest there is in the use of RNRs and how much desire there is for this
kind of information. So we really appreciate your time today and sharing with our audience
further information about RNR. So, with that, we will sign off. Thank you so much for joining us.

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