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Juvenile Justice Reform and Best Practices in Juvenile Systems NAMI 2005 Annual Convention Austin, Texas Eric W. Trupin, Ph.D. Department of Psychiatry.

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Presentation on theme: "Juvenile Justice Reform and Best Practices in Juvenile Systems NAMI 2005 Annual Convention Austin, Texas Eric W. Trupin, Ph.D. Department of Psychiatry."— Presentation transcript:

1 Juvenile Justice Reform and Best Practices in Juvenile Systems NAMI 2005 Annual Convention Austin, Texas Eric W. Trupin, Ph.D. Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine

2 Status of Mental Health System and Evidence-Based Treatments President’s Commission reports public mental health system is “in a shambles” (President’s New Freedom Commission Report, 2004) President’s Commission reports public mental health system is “in a shambles” (President’s New Freedom Commission Report, 2004) 90% of public mental health services do not deliver treatments programs or services that have empirical support 90% of public mental health services do not deliver treatments programs or services that have empirical support (Elliot, 1999; Henggeler et al., 2003)

3 Status of Mental Health System and Evidence-Based Treatments More than 550 different psychotherapies exist as well as an increasing number of empirically supported programs for multi-problem youth (Kazdin, 2003) More than 550 different psychotherapies exist as well as an increasing number of empirically supported programs for multi-problem youth (Kazdin, 2003) Many of the above treatments, services and programs are “evidence-based practices” (Hoagwood, Burns, et.al. 2001) Many of the above treatments, services and programs are “evidence-based practices” (Hoagwood, Burns, et.al. 2001) Startling discrepancies between high quality clinical promise and poor clinical practice (Hoagwood, et. al. in press) Startling discrepancies between high quality clinical promise and poor clinical practice (Hoagwood, et. al. in press)

4 Evidence-Based Treatments Poorly Disseminated Simplistic strategies for understanding process of implementation Simplistic strategies for understanding process of implementation Lack of attention to theories and methods from other fields (Marketing, anthropology, organizational behavior) that could enhance methods for adopting new approaches Lack of attention to theories and methods from other fields (Marketing, anthropology, organizational behavior) that could enhance methods for adopting new approaches

5 Characteristics of Empirically Supported Treatments with Children Focus on the development of skills, not on catharsis or insight Focus on the development of skills, not on catharsis or insight Utilization of manuals emphasizing adherence and fidelity Utilization of manuals emphasizing adherence and fidelity Consistent supervision of clinicians Consistent supervision of clinicians Homework or out-of-session work Homework or out-of-session work Focus on problems and solutions, rather than changing personality Focus on problems and solutions, rather than changing personality Active engagement and empowerment of family or caregiver Active engagement and empowerment of family or caregiver

6 Facts Facts Seventy percent of the nation’s mental health dollars for children and adolescents are spent on out-of-home placements. Seventy percent of the nation’s mental health dollars for children and adolescents are spent on out-of-home placements. (Burns & Friedman, 1990) No scientific evidence indicates that the most restrictive and expensive out-of-home placements (psychiatric hospitalization, criminal justice detentions) bring out desired clinical outcomes. No scientific evidence indicates that the most restrictive and expensive out-of-home placements (psychiatric hospitalization, criminal justice detentions) bring out desired clinical outcomes. (Sondheimer et al., 1994)

7 Facts Traditional office-based outpatient mental health care shows little evidence of effectiveness with children with serious emotional disorders. (Weisz, Weiss, and Donenberg, 1992) Traditional office-based outpatient mental health care shows little evidence of effectiveness with children with serious emotional disorders. (Weisz, Weiss, and Donenberg, 1992) Emerging community-based services are being disseminated without the necessary support and consistent supervision needed by community-based clinicians. Emerging community-based services are being disseminated without the necessary support and consistent supervision needed by community-based clinicians.

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9 Increased Focus Numbers of detained youth have tripled in last 2 decades Numbers of detained youth have tripled in last 2 decades 50-80% have Psychiatric or Substance Use Disorders, or both 50-80% have Psychiatric or Substance Use Disorders, or both 1 in 3 African American males, ages , are in jail, correctional facilities, on probation or parole 1 in 3 African American males, ages , are in jail, correctional facilities, on probation or parole

10 Increased Focus Over 70% recidivism rates common for juvenile offenders Over 70% recidivism rates common for juvenile offenders Costs to keep youth in secure facilities: New York: $85,000. Louisiana: $50,000. Costs to keep youth in secure facilities: New York: $85,000. Louisiana: $50, states spend more on prisons and detention facilities than on public colleges and universities 6 states spend more on prisons and detention facilities than on public colleges and universities

11 Recidivism Rates 58% of youth released from Washington’s Juvenile Rehabilitation Administration in were convicted of new felonies or misdemeanors within 18 months. (Source: Washington State Institute for Public Policy) 58% of youth released from Washington’s Juvenile Rehabilitation Administration in were convicted of new felonies or misdemeanors within 18 months. (Source: Washington State Institute for Public Policy) 45% were convicted of a new felony 45% were convicted of a new felony

12 Legal Mandates Results of case law: Results of case law: The right of access to care The right of access to care The right to receive care that is ordered The right to receive care that is ordered The right to a professional medical judgment The right to a professional medical judgment Federal Individuals with Disabilities Education Act (IDEA) Federal Individuals with Disabilities Education Act (IDEA) Conditions of Confinement Litigation Conditions of Confinement Litigation

13 Legal Mandates Civil Rights of Institutionalized Persons Act (CRIPA) – 1997 Civil Rights of Institutionalized Persons Act (CRIPA) – 1997 US Attorney General can investigate and litigate on conditions of confinement in state operated institutions US Attorney General can investigate and litigate on conditions of confinement in state operated institutions Special Litigation Section investigates for patterns or practices of violations of residents’ federal rights (not specific cases) Special Litigation Section investigates for patterns or practices of violations of residents’ federal rights (not specific cases) Methods include settlements, consent decrees Methods include settlements, consent decrees

14 Standards Utilized in Department of Justice Investigations Screening/Initial Assessment Screening/Initial Assessment Specialized Mental Health Assessment Specialized Mental Health Assessment Treatment Planning Treatment Planning Case Management Case Management Mental Health Counseling Mental Health Counseling

15 Standards Utilized in Department of Justice Investigations Management of Psychotropic Medications Management of Psychotropic Medications Crisis Management Crisis Management Suicide Prevention Suicide Prevention Physical Restraint Physical Restraint Chemical Restraint Chemical Restraint Youth Development/Treatment Programs Youth Development/Treatment Programs Institutional Practices Raising Mental Health Concerns Institutional Practices Raising Mental Health Concerns

16 Difficulties estimating prevalence of mental health disorders among youth in the juvenile justice system Regional variation Regional variation Use of standardized assessment tools limited Use of standardized assessment tools limited Under-sampling of certain populations Under-sampling of certain populations Youths’ report of mental health status may vary as a function of how long and in what environment they have been incarcerated Youths’ report of mental health status may vary as a function of how long and in what environment they have been incarcerated Youth, families, and institutional staff may be suspicious of research Youth, families, and institutional staff may be suspicious of research Inconsistent scope and quality of records to provide historical information supporting diagnoses Inconsistent scope and quality of records to provide historical information supporting diagnoses

17 “Mental Health and Juvenile Justice: Building a Model for Effective Service Delivery” Coordinated by Policy Research Associates Coordinated by Policy Research Associates Focus on determining the mental health status of youth, extent to which services are available and meeting needs, and level of satisfaction Focus on determining the mental health status of youth, extent to which services are available and meeting needs, and level of satisfaction Multiple sites (Texas, Louisiana, and Washington) Multiple sites (Texas, Louisiana, and Washington) Sampled from different “levels” of juvenile justice system (Detention, Secure, Group Homes) Sampled from different “levels” of juvenile justice system (Detention, Secure, Group Homes) Used standardized data collection instruments Used standardized data collection instruments

18 Preliminary Results 76.7% of participants met screening criteria for a mental health or substance use disorder 76.7% of participants met screening criteria for a mental health or substance use disorder Of those that met screening criteria, 85.8% met criteria for at least 1 diagnosis Of those that met screening criteria, 85.8% met criteria for at least 1 diagnosis 64.5% met criteria for a substance use disorder 64.5% met criteria for a substance use disorder

19 Characteristics of Empirically Supported Treatments Focus on the development of skills, not on catharsis or insight Focus on the development of skills, not on catharsis or insight Continuous assessment of progress Continuous assessment of progress Homework or out-of-session work Homework or out-of-session work Focus on problems and solutions, rather than changing personality Focus on problems and solutions, rather than changing personality Recognition of the importance of therapeutic relationship Recognition of the importance of therapeutic relationship

20 Stages of Intervention with Youth Engaging in Criminal Behavior Prevention of escalation of criminal behavior Prevention of escalation of criminal behavior Diversion Diversion Mentoring Mentoring Community-Based Treatment Programs Community-Based Treatment Programs Transition Transition Dialectical Behavior Therapy Dialectical Behavior Therapy Families In Transition Families In Transition

21 Early Intervention Targets youth who are beginning to engage in antisocial behavior and are at a high risk of having that behavior continue and escalate into more serious criminal activity Targets youth who are beginning to engage in antisocial behavior and are at a high risk of having that behavior continue and escalate into more serious criminal activity Focus is on identifying and intervening with negative influences in youths’ lives that contribute to antisocial behavior. Focus is on identifying and intervening with negative influences in youths’ lives that contribute to antisocial behavior.

22 Diversion Programs Designed to minimize negative impacts of incarceration Designed to minimize negative impacts of incarceration Divert youth involved in first-time or minor offenses into treatment, rather than secure facilities Divert youth involved in first-time or minor offenses into treatment, rather than secure facilities Target risk factors for recidivism, such as parent-child conflict and poor problem solving skills Target risk factors for recidivism, such as parent-child conflict and poor problem solving skills Can include assessment, counseling, tutoring, job training, substance abuse treatment, community service, restitution, psychoeducation Can include assessment, counseling, tutoring, job training, substance abuse treatment, community service, restitution, psychoeducation

23 Examples of Diversion Programs in King County, Washington Prime Time Project Prime Time Project Community Juvenile Accountability Act (CJAA) Community Juvenile Accountability Act (CJAA) Chemical Dependency Diversion Alternative (CDAA)/Juvenile Drug Courts Chemical Dependency Diversion Alternative (CDAA)/Juvenile Drug Courts Mental Health Disposition Alternative (MHDA) Mental Health Disposition Alternative (MHDA) Treatment Court Treatment Court

24 Community Based Treatment Provide rehabilitation services to youth and families in their homes and communities. Provide rehabilitation services to youth and families in their homes and communities. Views families as partners in creating an environment that supports change. Views families as partners in creating an environment that supports change.

25 Functional Family Therapy (FFT) A program designed to prevent the escalation or continuation of violent or serious externalizing behavior. A program designed to prevent the escalation or continuation of violent or serious externalizing behavior. Targets youth at risk of incarceration or other out-of-home placement due to behavior. Targets youth at risk of incarceration or other out-of-home placement due to behavior. Family behavioral intervention. Family behavioral intervention.

26 Phases of FFT 1. Motivation and Engagement 1. Motivation and Engagement Goals: develop alliance, reduce negativity, minimize hopelessness, reduce dropout, increase motivation for change Goals: develop alliance, reduce negativity, minimize hopelessness, reduce dropout, increase motivation for change 2.Behavior Change 2.Behavior Change Goals:develop and implement individualized change plans, change presenting delinquency behavior, build relational skills Goals:develop and implement individualized change plans, change presenting delinquency behavior, build relational skills 3.Generalization 3.Generalization Goals: maintain and generalize change, relapse prevention, engage community supports Goals: maintain and generalize change, relapse prevention, engage community supports

27 FFT Outcomes FFT significantly reduces recidivism for juvenile offenders FFT significantly reduces recidivism for juvenile offenders In Washington State, youth treated by competent FFT therapists had a 38% reduction in felony recidivism at 18-months post-release In Washington State, youth treated by competent FFT therapists had a 38% reduction in felony recidivism at 18-months post-release

28 Multisystemic Therapy (MST) Targets youth engaged in serious antisocial behavior and their families Targets youth engaged in serious antisocial behavior and their families Based on of the idea that behavior is determined by the various systems that affect and individual, including the family, school, peer group, and community. Based on of the idea that behavior is determined by the various systems that affect and individual, including the family, school, peer group, and community.

29 MST Continued Goal is to change the systems that create and sustain high-risk behavior. Goal is to change the systems that create and sustain high-risk behavior. Therapist works with family to identify function of problematic behavior and the factors that contribute to it. Therapist works with family to identify function of problematic behavior and the factors that contribute to it. Therapist works to change factors that contribute to and reinforce problematic behavior Therapist works to change factors that contribute to and reinforce problematic behavior Therapy takes place in the youth’s natural environment. Therapy takes place in the youth’s natural environment.

30 MST: Parents are seen as key agents of change A major goal is to enhance parents’ ability to monitor manage youth’s behavior, and give effective rewards and consequences. A major goal is to enhance parents’ ability to monitor manage youth’s behavior, and give effective rewards and consequences.

31 MST Outcomes Randomized controlled trials with youth post-incarceration indicate that MST is effective at reducing number of re-arrests, number of days incarcerated, peer- directed violence, and increasing family cohesion and the number of youth who did not recidivate at all. Randomized controlled trials with youth post-incarceration indicate that MST is effective at reducing number of re-arrests, number of days incarcerated, peer- directed violence, and increasing family cohesion and the number of youth who did not recidivate at all.

32 MST Outcomes: Recidivism In a randomized study of 200 juvenile offenders, youth who participated in MST had a lower (22.1%) rate of recidivism than did youth who participated in individual therapy (71.4%) at 4-year follow-up. (Borduin, Mann, Cone, Henggeler, Fucci, Blaske, & Williams, 1995) In a randomized study of 200 juvenile offenders, youth who participated in MST had a lower (22.1%) rate of recidivism than did youth who participated in individual therapy (71.4%) at 4-year follow-up. (Borduin, Mann, Cone, Henggeler, Fucci, Blaske, & Williams, 1995)

33 Treatment Within Juvenile Justice Settings

34 Juvenile Rehabilitation Administration’s Integrated Treatment Model Used in JRA’s residential programs Used in JRA’s residential programs Framework for treatment planning across continuum of care Framework for treatment planning across continuum of care

35 Parameters of the Integrated Treatment Model (ITM) Cognitive-behavioral basis Cognitive-behavioral basis Family-focused Family-focused Evidence-based approaches implemented Evidence-based approaches implemented Skill-based Skill-based

36 Integrated Treatment Model: Assessment Identification and prioritization of treatment needs is a major goal Identification and prioritization of treatment needs is a major goal Use of standardized, valid diagnostic measures (Diagnostic Interview Schedule for Children) Use of standardized, valid diagnostic measures (Diagnostic Interview Schedule for Children) Treatment heirarchy is established, targeting Treatment heirarchy is established, targeting Threats of harm to self or others Threats of harm to self or others Physical or sexual aggression Physical or sexual aggression Escape ideation or attempts Escape ideation or attempts Treatment-interfering behaviors Treatment-interfering behaviors Motivation and engagement Motivation and engagement Quality-of-life interfering behaviors Quality-of-life interfering behaviors Significant treatment considerations Significant treatment considerations

37 Integrated Treatment Model: Methods of Change Behavior Modification: Reinforcement, punishment, shaping, extinction, contingency management, cue removal and exposure Behavior Modification: Reinforcement, punishment, shaping, extinction, contingency management, cue removal and exposure Coaching and role playing Coaching and role playing Motivation enhancement Motivation enhancement Validation Validation Cognitive restructuring Cognitive restructuring Skills training (Dialectical Behavior Therapy) Skills training (Dialectical Behavior Therapy)

38 Components of Integrated Treatment Model Dialectical Behavior Therapy Dialectical Behavior Therapy Substance abuse treatment Substance abuse treatment Relapse prevention Relapse prevention Sex-offender treatment Sex-offender treatment Aggression-replacement therapy Aggression-replacement therapy Functional family therapy Functional family therapy Family Integrated Treatment Family Integrated Treatment

39 Dialectical Behavior Therapy Developed by Marsha Linehan for the treatment of Borderline Personality Disorder (BPD) Developed by Marsha Linehan for the treatment of Borderline Personality Disorder (BPD) Goal is to reduce problems associated with emotional dysregulation Goal is to reduce problems associated with emotional dysregulation

40 Emotional Dysregulation The inability to monitor, evaluate, and change emotional responses The inability to monitor, evaluate, and change emotional responses Impulsivity Impulsivity Intense emotional responses Intense emotional responses Slow return to normal after emotional arousal Slow return to normal after emotional arousal

41 Emotional Dysregulation A hallmark symptom of Borderline Personality Disorder A hallmark symptom of Borderline Personality Disorder Also related to a range of problems commonly seen in the Juvenile Justice Population Also related to a range of problems commonly seen in the Juvenile Justice Population Substance abuse, depression, anxiety, poor impulse control, poor anger management Substance abuse, depression, anxiety, poor impulse control, poor anger management DBT: a promising treatment for juvenile offenders? DBT: a promising treatment for juvenile offenders?

42 What is DBT? Emphasis on mindfulness Emphasis on mindfulness Behavioral therapy components Behavioral therapy components Goal-focused interventions Goal-focused interventions Behavior chain analysis is used to identify antecedents and consequences of behavior, and to prompt consideration of alternative courses of action Behavior chain analysis is used to identify antecedents and consequences of behavior, and to prompt consideration of alternative courses of action Recognition that one needs to change one’s behavior in order to change one’s feelings Recognition that one needs to change one’s behavior in order to change one’s feelings

43 DBT Skills Core Mindfulness Core Mindfulness Emotion Regulation Emotion Regulation Distress Tolerance Distress Tolerance Interpersonal Effectiveness Interpersonal Effectiveness

44 Dialectics: Acceptance vs. Change Validation Validation Patients’ emotional, cognitive, and behavioral responses are understandable in the context of the environment and the patient’s skill level Patients’ emotional, cognitive, and behavioral responses are understandable in the context of the environment and the patient’s skill level Patient may not have created his/her problems, but he/she is responsible for solving them Patient may not have created his/her problems, but he/she is responsible for solving them Therapist coaches patient on more effective behavioral responses Therapist coaches patient on more effective behavioral responses

45 DBT in Juvenile Justice Settings Delivered through groups, individual therapy, and daily interactions with staff Delivered through groups, individual therapy, and daily interactions with staff Teaches behavioral analysis, cognitive restructuring, skills coaching Teaches behavioral analysis, cognitive restructuring, skills coaching Integrated into the culture of the institution Integrated into the culture of the institution

46 Is DBT effective in juvenile justice settings? Outcome research is limited Outcome research is limited Girls in mental health cottage who received DBT had significantly lower 12 month felony recidivism rate than those who were residents of the cottage before the DBT program began(10% vs. 24%). (WSIPP, 2002) Girls in mental health cottage who received DBT had significantly lower 12 month felony recidivism rate than those who were residents of the cottage before the DBT program began(10% vs. 24%). (WSIPP, 2002) Punitive actions by staff in mental health cottage decreased when cottage began implementing DBT. (Trupin, Stewart, Beach & Boesky, 2002) Punitive actions by staff in mental health cottage decreased when cottage began implementing DBT. (Trupin, Stewart, Beach & Boesky, 2002)

47 Transitioning Youth From Incarceration to the Community How can we give youth with co-occurring disorders the skills they will need to avoid recidivating? How can we give youth with co-occurring disorders the skills they will need to avoid recidivating?

48 Family Integrated Transitions (FIT) A family- and community-based treatment for youth with co-occurring mental health and substance abuse diagnoses who are being released from secure institutions in Washington State’s Juvenile Rehabilitation Administration A family- and community-based treatment for youth with co-occurring mental health and substance abuse diagnoses who are being released from secure institutions in Washington State’s Juvenile Rehabilitation Administration

49 FIT targets the multiple determinants of antisocial behavior Multisystemic Therapy framework to change the systems that create the reinforcement contingencies for behavior Multisystemic Therapy framework to change the systems that create the reinforcement contingencies for behavior Dialectical Behavior Therapy to promote emotional and behavioral regulation Dialectical Behavior Therapy to promote emotional and behavioral regulation Motivational Enhancement Therapy to promote engagement in treatment Motivational Enhancement Therapy to promote engagement in treatment Relapse Prevention to give youth skills to promote sustained abstinence Relapse Prevention to give youth skills to promote sustained abstinence

50 Family Integrated Transition (FIT): Target Population Ages 11 to 17 at intake Ages 11 to 17 at intake Substance abuse or dependence disorder AND Substance abuse or dependence disorder AND Axis I Disorder OR currently prescribed psychotropic medication OR demonstrated suicidal behavior in past 6 months Axis I Disorder OR currently prescribed psychotropic medication OR demonstrated suicidal behavior in past 6 months At least 4 months left on sentence At least 4 months left on sentence Residing in service area Residing in service area

51 Effects of Participation in FIT on Recidivism Recidivism of youth who participated in FIT was compared with recidivism of youth were eligible for FIT, but lived outside of the service area Recidivism of youth who participated in FIT was compared with recidivism of youth were eligible for FIT, but lived outside of the service area At 18 months post-release, felony recidivism was 34% lower for FIT clients (27%) than for comparison youth (41%). At 18 months post-release, felony recidivism was 34% lower for FIT clients (27%) than for comparison youth (41%). (Washington State Institute of Public Policy, 2004)

52 Cost-Effectiveness of FIT Savings in criminal justice costs: $11,749 Savings in criminal justice costs: $11,749 Savings in avoided criminal victimizations: $16,466 Savings in avoided criminal victimizations: $16,466 Total savings per participant: $28,215 Total savings per participant: $28,215 Total cost per participant: $8,968 Total cost per participant: $8,968 Benefit to cost ratio: $3.15 Benefit to cost ratio: $3.15 (Washington State Institute of Public Policy, 2004)

53 How do the different approaches to treating youth in the juvenile justice system compare with each other?

54 -12% -13% -31% -14% -4% -8% 10% -5% -2% -1% -31% -25% -18% -37% -27% -5% 0% -4% -14% 13% -17% -15% -12% 10% -80%-60%-40%-20%0%20%40% Early Childhood Education for Disadvantaged Youth (N = 6) Seattle Social Development Project (N = 1) Quantum Opportunities Program (N = 1) Children At Risk Program (N = 1) Mentoring (N = 2) National Job Corps (N = 1) Job Training Partnership Act (N = 1) Diversion with Services (vs. Regular Court) (N = 13) Diversion-Release, no Services (vs. Regular Court) (N = 7) Diversion with Services (vs. Release without Services) (N = 9) Multi-Systemic Therapy (N = 3) Functional Family Therapy (N = 7) Aggression Replacement Training (N = 4) Multidimensional Treatment Foster Care (N = 2) Adolescent Diversion Project (N = 5) Juvenile Intensive Probation (N = 7) Intensive Probation (as alternative to incarceration) (N = 6) Juvenile Intensive Parole Supervision (N = 7) Coordinated Services (N = 4) Scared Straight Type Programs (N = 8) Other Family-Based Therapy Approaches (N = 6) Structured Restitution for Juvenile Offenders (N = 6) Juvenile Sex Offender Treatment (N = 5) Juvenile Boot Camps (N = 10) Lower Recidivism Higher Recidivism The number in each bar is the "effect size" for each program, which approximates a percentage change in recidivism rates. The length of each bar are 95% confidence intervals. Type of Program, and the Number (N) of studies in the Summary Source: Meta-analysis conducted by the Washington State Institute for Public Policy The Estimated Effect on Criminal Recidivism for Different Types of Programs for Youth and Juvenile Offenders

55 Economic Estimates From National Research For Adult & Juvenile Justice and Prevention Programs Prevention Programs Juvenile Offender Programs -$20,000$0$20,000$40,000$60,000$80,000$100,000 Net Gain Per Person in Program Break-Even Point Net Loss Drug Courts Ther. Commun. w/Aftercare In-Prison Non Res.Drug TX Sex Off. Prog, Cog. Beh.. Intensive Super, no TX Int Super, w/TX Adult Basic Ed. Vocational Ed. Intensive Super. Probation Functional Family Therapy MultiSystemic Therapy Aggression Replacemnt Trng Coordinated Services Scared Straight Programs Intensive Super. Parole Treatment Foster Care Boot Camps Nurse Home Visitation Early Childhood Education Seattle Soc. Devlp. Project Quantum Opportunities Job Training Part. Act Mentoring Adult Offender Programs

56 Implementation Challenges Conflicting roles of the juvenile justice system: punishment versus treatment Conflicting roles of the juvenile justice system: punishment versus treatment Variable commitment to treatment among institution staff Variable commitment to treatment among institution staff Challenges of conducting treatment outcome research with incarcerated youth Challenges of conducting treatment outcome research with incarcerated youth Intensive training and supervision needs Intensive training and supervision needs Logistical difficulty in implementing family based treatments in rural settings Logistical difficulty in implementing family based treatments in rural settings

57 “Vision without action is a daydream. Action without vision is a nightmare.” Japanese Proverb


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