Annals of Research and Knowledge (ARK) 4/1/2014 Targeting Interventions by Risk, Need & Responsivity Douglas B. Marlowe, J.D., Ph.D., FCPP

Risk Principle Not necessarily a risk for violence or dangerousness Difficult prognosis or lesser amenability to treatment The higher the risk level, the more intensive the supervision and accountability should be, and vice versa Mixing risk levels is contraindicated

Prognostic Risks Current age < 25 years Delinquent onset < 16 years Substance abuse onset < 14 years Prior rehabilitation failures History of violence Antisocial Personality Disorder Psychopathy Familial history of crime or addiction Criminal or substance abuse associations

Annals of Research and Knowledge (ARK) 4/1/2014 Need Principle Clinical syndromes or impairments (diagnosis) The higher the need level, the more intensive the treatment or rehabilitation services should be, and vice versa Mixing need levels is contraindicated

Treatment Courts (e.g., Drug Courts) Deflection; Banked probation Risk & Needs Matrix High Risk Low Risk Supervision Treatment Pro-social habilitation Adaptive habilitation Treatment • (Pro-social rehabilitation) • Adaptive rehabilitation Treatment Courts (e.g., Drug Courts) Treatment Diversion High Needs Supervision Pro-social habilitation (Adaptive habilitation) Secondary prevention Diversion Intensive Probation (ISP, HOPE) Deflection; Banked probation Low Needs

Annals of Research and Knowledge (ARK) 4/1/2014 Specific Responsivity Order and timing of intervention is crucial: Responsivity needs — interfere with rehabilitation Criminogenic needs — cause or exacerbate crime Maintenance needs — degrade rehabilitation gains Humanitarian needs — cause distress Restorative needs — e.g., restitution, community svc. Continuing-care plan to address unmet needs Each phase advancement increases the odds of subsequent phase advancements

Annals of Research and Knowledge (ARK) 4/1/2014 Case Planning Type 1 Case (Dual Diagnosis) 5 phases Stabilization: - Housing assistance - Stabilize cravings, withdrawal, anhedonia - Mental health tx yes Criminogenic: - Addiction treatment - Delinquent peer affiliations - Pro-social regimen; structure - Family crisis mgmt. yes Responsivity Needs? Criminogenic Needs? no no Pro-Social Habilitation: - Criminal thinking - Adaptive problem-solving 18 – 24 mos. ≥ 300 hrs. Maintenance: - Vocational / educational counseling - Life skills training - Therapy / recovery svcs * Restitution; community svc; fees ** HIV/STD prevention ** Overdose prevention & reversal yes Maintenance Needs? Continuing Care no *Restorative justice interventions **Humanitarian Needs

Annals of Research and Knowledge (ARK) 4/1/2014 Case Planning Type 2 Case (Addiction) 4 phases Stabilization: - Housing assistance - Stabilize cravings, withdrawal, anhedonia - Mental health tx yes Criminogenic: - Addiction treatment - Delinquent peer affiliations - Pro-social regimen; structure - Family crisis mgmt. yes Responsivity Needs? Criminogenic Needs? no no Pro-Social Habilitation: - Criminal thinking - Adaptive problem-solving 12 – 18 mos. ≥ 200 hrs. Maintenance: - Vocational / educational counseling - Life skills training - Therapy / recovery svcs * Restitution; community svc; fees ** HIV/STD prevention ** Overdose prevention & reversal yes Maintenance Needs? Continuing Care no *Restorative justice interventions **Humanitarian Needs

Annals of Research and Knowledge (ARK) 4/1/2014 Case Planning Stabilization: - Housing assistance - Stabilize cravings, withdrawal, anhedonia - Mental health tx yes Criminogenic: - Addiction treatment - Delinquent peer affiliations - Pro-social regimen; structure - Family crisis mgmt. yes Responsivity Needs? Criminogenic Needs? no Type 3 (Socialized) 3 phases no Pro-Social Habilitation: - Criminal thinking - Adaptive problem-solving ~ 12 mos. ~ 150 hrs. Maintenance: - Vocational / educational counseling - Life skills training - Therapy / recovery svcs * Restitution; community svc; fees ** HIV/STD prevention ** Overdose prevention & reversal yes Maintenance Needs? Continuing Care no *Restorative justice interventions **Humanitarian Needs

Annals of Research and Knowledge (ARK) 4/1/2014 Case Planning Stabilization: - Housing assistance - Stabilize cravings, withdrawal, anhedonia - Mental health tx yes Criminogenic: - Addiction treatment - Delinquent peer affiliations - Pro-social regimen; structure - Family crisis mgmt. yes Responsivity Needs? Criminogenic Needs? no no Pro-Social Habilitation: - Criminal thinking - Adaptive problem-solving ~ 6 – 12 mos. < 100 hrs. Type 4 Case: (Situational) 2 phases Maintenance: - Vocational / educational counseling - Life skills training - Therapy / recovery svcs * Restitution; community svc; fees ** HIV/STD prevention ** Overdose prevention & reversal yes Maintenance Needs? Continuing Care no *Restorative justice interventions **Humanitarian Needs

Annals of Research and Knowledge (ARK) 4/1/2014 Case Planning Stabilization: - Housing assistance - Stabilize cravings, withdrawal, anhedonia - Mental health tx yes Criminogenic: - Addiction treatment - Delinquent peer affiliations - Pro-social regimen; structure - Family crisis mgmt. yes Responsivity Needs? Criminogenic Needs? no no Pro-Social Habilitation: - Criminal thinking - Adaptive problem-solving Type 5 Case: (Deflection) 1 phase ~ 3 mos. ~ 12 - 26 hrs. Maintenance: - Vocational / educational counseling - Life skills training - Therapy / recovery svcs * Restitution; community svc; fees ** HIV/STD prevention ** Overdose prevention & reversal yes Maintenance Needs? Continuing Care no *Restorative justice interventions **Humanitarian Needs

Shaping Behavior Don’t expect too much Don’t expect too little Learned helplessness, ratio burden, ceiling effects Don’t expect too little Habituation, complacency Proximal vs. distal goals Phase specificity What was once distal becomes proximal

Treat or Punish? Substance Dependence or Addiction

Treat or Punish? Substance Dependence or Addiction Triggered binge pattern Cravings or compulsions Withdrawal symptoms

Abstinence is a distal goal Treat or Punish? Substance Dependence or Addiction Triggered binge pattern Cravings or compulsions Withdrawal symptoms Abstinence is a distal goal }

Abstinence is a distal goal Treat or Punish? Substance Dependence or Addiction Triggered binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Abstinence is a distal goal }

} } Treat or Punish? Substance Dependence or Addiction Substance Abuse Triggered binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Abstinence is a distal goal Abstinence is a proximal goal } }

} } Treat or Punish? Collateral needs Substance Dependence or Addiction Triggered binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Collateral needs Dual diagnosis Chronic medical condition (e.g., HIV+, HCV, diabetes) Homelessness, chronic unemployment Abstinence is a distal goal Abstinence is a proximal goal } }

} } } Treat or Punish? Collateral needs Substance Dependence or Addiction Triggered binge pattern Cravings or compulsions Withdrawal symptoms Substance Abuse Collateral needs Dual diagnosis Chronic medical condition (e.g., HIV+, HCV, diabetes) Homelessness, chronic unemployment Abstinence is a distal goal Abstinence is a proximal goal } Regimen compliance is proximal } }

Pre-Disposition Assessment Require assessment of risk and need before disposition E.g., as part of a pre-sentence investigation (PSI) Use immunity especially at pre-adjudication stage Valid, reliable, & culturally unbiased instruments Substance abuse vs. dependence diagnosis guides treatment conditions and response to technical violations involving new drug use Automate the if then decisions