1. START NOW: Implementing and Evaluating a Cognitive Behavioral Intervention for Offenders Susan Sampl, PhD Robert L. Trestman, PhD, MD Kirsten Shea, MBA Malini Varma, MA Walter Krauss, PsyD Amy Houde, MSW, LCSW Correctional Managed Health Care University of Connecticut Health Center Farmington CT USA

2. OBJECTIVES 1.Understand the theoretical and research background of START NOW 2. Articulate recommendations for successfully implementing a structured cognitive behavioral intervention within corrections. 3. Identify methods and results of evaluating START NOW in correctional settings.

3. DISCLOSURE No financial Conflicts of Interest

5. Using SCID II with 508 inmates in Connecticut jails in an IRB approved National Institute of Justice Study: (Trestman et al, 2007) Personality DisorderMale (N=307) Female (N=201) Total (N=508) Freq% % % Paranoid299.62010.1499.8 Borderline 3912.94523.28416.9 Antisocial12039.55327.017334.6

7. Participants: English-speaking women (n=18) and men (n=45) Results: Significant reduction in targeted behavior was found from baseline to following the16 week DBT-CM skills treatment groups. Both case management and DBT coaching were significant at 12month follow-up. Conclusions: The study supports the value of DBT-CM for management of aggressive behaviors in prison settings.

9. PARTICIPANTS: 38 male adolescents RESULTS: Significant changes were found in physical aggression, distancing coping methods, and number of disciplinary tickets for behavior. CONCLUSION: The study supports the value of DBT-CM for the management of incarcerated male adolescents with difficult-to-manage aggressive behaviors.

10. CHALLENGES: TRANSITION FROM RESEARCH TO PRACTICE Costs of training Staff turnover Optimum language level Costs and copyright issues

11. Background of START NOW: Research START NOW is an evidence-informed coping skills therapy designed to treat offenders with behavioral disorders and associated behavioral problems. START NOW grew out of National Institute of Justice funded research at the University of CT Health Center and the Connecticut DOC. http://cmhc.uchc.edu/programs_services/startnow.aspx

12. Structure & Design of START NOW 32 CBT/Coping Skills group sessions Clinical Tools –Participant workbooks 5 th grade reading level Gender specific Spanish version available –Facilitator manual Highly structured, detailed Basic scripts and examples provided –Standardized protocol and tools for training and fidelity monitoring

13. Background of START NOW: Theory An integrative skills training model informed by a number of theoretical approaches & models- –Primarily a cognitive behavior therapy (CBT) model –Includes motivational interviewing principles & practices to enhance motivation for change –Infused with elements of cognitive neuro-rehabilitation, in consultation with correctional neuro-cognitive researcher, D. Fishbein (Fishbein et al., 2009). –Theories of criminal behavior, including relevant examples in participant workbooks.

14. CBT for a Correctional Population There is much support in the literature for the use of CBT in the treatment of criminal conduct (Thigpen, 2007; Wilson, Bouffard, & Mackenzie, 2005). Several meta analyses support the use of CBT to reduce criminal recidivism (Pearson, Lipton, Cleland, & Yee, 2002). Group oriented CBT was found to reduce criminal behavior 20-30% compared to control (Wilson, Bouffard, & Mackenzie, 2005).

15. CBT within START NOW CBT procedures during group: –Brainstorming –Role play –problem-solving –shaping of desired behaviors “Real life practice exercises” between group sessions “ABC System” for functional analysis of behavior

17. Incorporating Motivational Interviewing Focuses on developing motivation for change (Miller & Rollnick, 2002), including changing criminal behavior (Chambers et al., 2008; Howells & Day, 2006). MI & CBT have been combined in other effective interventions (Dennis et al., 2004; Diamond et al., 2002; Steinberg et al., 2005). Research supports use of MI with offenders, resulting in improved addictions treatment compliance (Davis et al., 2003), reduced criminal attitude and substance related problems (Harper & Hardy, 2000), reduced reconviction rates (Antiss, Polascek & Wilson, 2011), and reduced DUI behaviors in adolescents (Stein et al., 2006).

18. Motivational Interviewing Influence on START NOW strategies: Emphasis on accepting ambivalence about change and “rolling with resistance” “Supporting self-efficacy” through focusing on strengths Many opportunities to elicit change talk & work through ambivalence are built into the START NOW clinical materials

19. Offender Focused Interventions Influence on START NOW strategies: Illustrative examples & coping behaviors are relevant to forensic situations Concepts & language are simplified given cognitive limitations of many offenders Numerous icons included in the participant workbook- especially useful with TBI or verbally limited participants Facilitator manual includes numerous tips for engaging difficult-to-engage participants: eg, shaping by reinforcing any movement toward the desired behavioral change.

20. Standard CBT Session Structure Introduce any new members & review group rules (5 min.) Review of real life practice exercise from previous session (10 – 15 min.) Practice Focusing or ABC Skills (10 – 15 min.) Rationale & overview of new coping skill ( 10 min.) In-session practice exercise (15 min.) Assign new real life practice exercise (5 min.)

21. Unit 1- My Foundation: Starting with Me Focuses on developing increased self-control & ability to cope with stressors Includes setting a treatment goal, increasing wellness skills, accepting yourself & your situation, & enhancing your spirituality, values & personal boundaries.

22. Unit 2- My Emotions: Dealing with Upset Feelings Includes: Recognizing & understanding emotions. Coping with emotions through actions, or through thoughts & imagery. Coping with depression, anger, anxiety & grief.

23. Unit 3- My Relationships: Connecting with Others Focuses on developing positive relationship skills including: –Listening skills –Assertiveness –Setting boundaries –Asking for support –Avoiding destructive relationships –Responding to feedback –Coping with rejection

24. Unit 4- My Future: Setting & Meeting my Goals Focuses on preparing for a positive future by: –Developing hope –Setting realistic goals & breaking them down into steps –Learning problem solving skills –Learning to set & meet educational & vocational goals

25. Developing & Maintaining Fidelity of Implementation Training, in absence of coaching, is insufficient. (National Implementation Research Network- Fixsen et al., 2005) Network of START NOW Trainers developed covering the entire CT DOC system START NOW Trainer Role: –Serve as local expert & point of communication –Provide centralized and local training –Observe groups for fidelity monitoring & coaching

26. Supporting the Sustainability of START NOW Enhanced by a standardized manual-guided intervention Results in reasonable cost of training to allow for staff turnover within corrections Requires a committed coordinating team, as well as an organized system to track provision of care

28. Creating an Information System

30. DATA! Repository for resources Internal External Program generated data Outcome Measures Methods to retrieve data/Reporting tools

32. http://cmhc.uchc.edu/programs_services/startnow.aspx

33. Program Generated Data Group Data Attendance Data Program Outcomes Satisfaction Questionnaires

36. Building a data set Identifying information –Inmate name –Inmate number Start date of group End date of group Number of sessions completed

38. Outcome Measures Identify available data

40. Outcome Measures Identify available and relevant data pieces Disciplinary Tickets Days spent as MH inpatient Psychological measure assessment (computerized) Buss-Perry Aggression Questionnaire Inventory of Interpersonal Problems Barrett Impulsiveness Scale

41. Outcome Measures Target new measures Self-injurious behaviors Medication adherence Crisis encounters per month Recidivism

42. Method to Retrieve Data / Reporting Canned reports through MS Access application Custom reports requested through IT Data Dashboards (coming soon)

43. START NOW Program 13 CDOC facilities have active START NOW programs 57 clinicians are currently trained 215 individuals are in active treatment Data as of February 28, 2013

44. START NOW Participant Satisfaction Data Through December 2012

45. Satisfaction Survey Procedures N=619 10 questions; 8 Likert Scale, 2 open-ended Completed at the end of every unit Anonymous

46. Overall N: 619 U1 N: 210 U2 N: 158 U3 N: 127 U4 N: 124 START NOW Participant Satisfaction Data Q1: How would you rate the quality of the START NOW unit you just completed? 1=Poor, 2=Fair, 3=Good, 4=Excellent

47. START NOW Participant Satisfaction Data Q5: How satisfied are you with the amount of help you have received? 1=Quite Dissatisfied, 2=Indifferent or mildly dissatisfied, 3=Mostly satisfied, 4=Very satisfied Overall N: 619 U1 N: 210 U2 N: 158 U3 N: 127 U4 N: 124

48. START NOW Participant Satisfaction Data Q6: Has this START NOW unit helped you to deal more effectively with your problems? 1=No, it seemed to make things worse, 2=No, it really didn’t help, 3=Yes, it helped, 4=Yes, it helped a great deal Overall N: 619 U1 N: 210 U2 N: 158 U3 N: 127 U4 N: 124

49. START NOW Participant Satisfaction Data Q7: Has participation in this START NOW unit helped you cope with daily life in prison/jail? 1=No, it seemed to make things worse, 2=No, it really didn’t help, 3=Yes, it helped, 4=Yes, it helped a great deal Overall N: 619 U1 N: 210 U2 N: 158 U3 N: 127 U4 N: 124

50. Overall N: 619 U1 N: 210 U2 N: 158 U3 N: 127 U4 N: 124 START NOW Participant Satisfaction Data Q8: If you were to seek help again would you participate in this START NOW unit? 1=No, definitely not, 2=No, I don’t think so, 3=Yes, I think so, 4=Yes, definitely

51. START NOW Participant Satisfaction Data Q9: What were the activities or topics you liked the most about this unit? An open-ended question for which responses were categorized through qualitative analysis. Frequencies of the top 6 responses are shown below: Overall N: 615

52. START NOW Participant Satisfaction Data Q10: What would you change about this unit to make it better? An open-ended question for which responses were categorized through qualitative analysis. Frequencies of the top 6 responses are shown below: Overall N: 506

53. ADAPTATION of START NOW Alternative to Incarceration (AIC) Program DMHAS AIC program for Dually- Diagnosed SMI clients (ASIST) Significant effect for START NOW on reduced re-incarceration (b=-.024, S.E.=0.008, p=0.003, OR=0.98); Cox regression, adjusted for illness severity Dose Response: Each START NOW session yields a 2.0% reduction in the odds of re- incarceration Frisman LK, Lin H, Rodis E, & Grzelak J. Final Report: Evaluation of the ASIST Program. CT Department of Mental Health & Addiction Services, internal document, 9/12/11

54. SUMMARY These interventions have a role to play in empowering individuals to gain greater control over their lives as they work toward recovery and effective integration into the community Implementation of evidence-based or evidence- informed treatment has many real world challenges that can be met both in institutional correctional and forensic settings