Representing Your NGRI Client*

Representing Your NGRI Client : Representing Your NGRI Client Joel A. Dvoskin, Ph.D., ABPP University of Arizona Medical School joelthed@aol.com & Elissa Ball, M.D. Colorado Mental Health Institute at Pueblo & Linda Dotson, RN Director, Forensic Community-Based Services

Colorado Mental Health Institute at Pueblo (CMHIP) : Colorado Mental Health Institute at Pueblo (CMHIP) Some Facts and Figures

Colorado Mental Health Institute at Pueblo : Colorado Mental Health Institute at Pueblo Bed Capacity and Legal Status Civil Commitments Correctional Transfers Court-Ordered Evaluations Incompetent to Proceed (ITPs) Not Guilty by Reason of Insanity* (NGRIs)

CMHIP NGRIs Length of Stay : CMHIP NGRIs Length of Stay Pre-Law Suit Post-Law Suit During Settlement

CMHIP NGRIs : CMHIP NGRIs Diagnostic Categories Types of Crime

CMHIP NGRIs Treatment Programs : CMHIP NGRIs Treatment Programs Evidence-Based & Recovery Model Programs: Motivational Interviewing (MI) Dialectical Behavioral Therapy (DBT) Cog Skills (R&R) Social Learning Program (SLP) Liberman Skills Training Sexual Treatment & Evaluation Program (STEP)

NGRI Treatment Progression : NGRI Treatment Progression Supervised On-Grounds Privileges Unsupervised On-Grounds Privileges Supervised Off-Grounds Privileges Unsupervised Off-Grounds Privileges Community Placement Conditional Release

Role Definition : Role Definition Our Patients = Your Clients Defense? Advocacy Expert Witness? Objective Opinion

Role Definition: : Role Definition: Unresolved Dialectics Neutrality versus Greatest Knowledge Legal Advocacy versus Patient’s Best Interests

Preparing Your Witness : Preparing Your Witness Tell them what you will be asking Ask them if they’d like additional questions Ask if they want feedback Narrow vs. Broad Questions

Preparing Your WitnessRemind them: : Preparing Your WitnessRemind them: Experts should answer hostile questions honestly There is often no need to elaborate. If they try to defend themselves, they will only look defensive Dignity enhances credibility

There are at least two sides to every story. : There are at least two sides to every story. If every word out of your expert’s mouth supports your side, your expert is probably not telling "the whole truth," and you both deserve to get embarrassed.

Remind them: “You are most credible… : Remind them: “You are most credible… … when you admit your ignorance.” Discuss: the value of the “preemptive strike”

Preparing Your Witness for Next Time : Preparing Your Witness for Next Time If requested: Give them honest, balanced feedback

Break : Break

CMHIP NGRI Treatment : CMHIP NGRI Treatment Legal Criteria for Release in Colorado

CMHIP NGRI Treatment : CMHIP NGRI Treatment Principles of Effective Forensic Treatment

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

CMHIP NGRIs Treatment Programs : CMHIP NGRIs Treatment Programs Evidence-Based & Recovery Model Programs: Motivational Interviewing (MI) Dialectical Behavioral Therapy (DBT) Cog Skills (R&R) Social Learning Program (SLP) Liberman Skills Training Sexual Treatment & Evaluation Program (STEP)

Learning from Failure… : Learning from Failure… The Risk Assessment

“Predicting is hard, especially the future.” : “Predicting is hard, especially the future.” Yogi Berra

“You can predict things, after they happen.” : “You can predict things, after they happen.” Ionesco

Learning from Failure : Learning from Failure Models of risk assessment Actuarial Structured professional judgments Unguided clinical judgement Anamnestic assessment strategies The way we usually do it

Slide 24 : Clinical Judgement Actuarial Assessment

Clinical Judgement… : Clinical Judgement…

Anamnestic Assessment : Anamnestic Assessment Learn from the person’s history List instances of failure from the past Clinical and social circumstances Risk-laden situations (RLS) Identify in advance Avoid Escape Barriers to identifying and avoiding RLS Learning from failure – feedback loops

Actuarial Prediction of Risk : Actuarial Prediction of Risk

Prediction, Risk Assessment, and Risk Management : Prediction, Risk Assessment, and Risk Management Tolerable risk depends upon the consequences of errors Type I errors Type II errors

Slide 29 : What do we mean by Violence?

Violent? : Violent?

Violence: Parameters : Violence: Parameters Nature Severity Imminence Frequency Duration

Nature of Violence : Nature of Violence What kind of violence? What is the motivation? Who are the likely victims? Scenarios of risk

Severity of Violence : Severity of Violence What would be the physical harm to victims? Could violence escalate to life threatening levels? Consider patients as victims as well as perpetrators of violence

Imminence : Imminence How soon might the violence occur? Are there any warning signs that might signal that violence risk is increasing or imminent?

Frequency of Violence : Frequency of Violence How often might the violence occur? Is the violence risk chronic or acute (time limited)?

Likelihood : Likelihood In general, how frequent is this type of violence? How frequently has this person committed this type of violence? What is the probability that this person will commit this type of violence?

Risk Assessment versus Risk Management : Risk Assessment versus Risk Management

Risk Assessment and Risk Management : Risk Assessment and Risk Management Assessment of risks Identify risk-laden situations Assess skill deficits and strengths that relate to risk-laden situations Teach avoiding and escaping from risky situations It’s all about skills

Person and situation : Person and situation Behavior in context All behavior is an interaction between a person and a situation. Violence is no exception. The role of neighborhoods

Risk Assessment : Risk Assessment Actuarial Tools Structured Professional Judgment Instruments Measures of Recidivism Strengths and Weaknesses

Risk Assessment at CMHIP : Risk Assessment at CMHIP The Tools we use and why PCL-R (Psychopathy CheckList Revised) VRS (Violence Risk Scale) VRAG (Violence Risk Appraisal Guide) HCR:20 (H=History, C=Clinical, R=Risk) STATIC, STABLE, and ACUTE risk of sexual violence

QuestionsLunch : QuestionsLunch

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

Static Risk Factors : Static Risk Factors

Gender : Gender Generally males > females, but Female psychiatric pts = male psychiatric pts Female violence occurs more towards family members Mental Health Professionals are less accurate in assessing female violence

Age : Age Generally, increased age is associated with decreased violence, except For individuals meeting criteria for Psychopathy

Early vs. Late Starters : Early vs. Late Starters Early: stable pattern of antisocial behavior from childhood or adolescence Late: no antisocial or criminal behavior until symptoms become apparent

Behavior in Context : Behavior in Context Good behavior in hospital may not predict lawful behavior in community The dangers of teaching people only to obey Why CMHI-P wants to teach people how to make better decisions The value of some failures

More Static Risk Factors : More Static Risk Factors Weapon Use Failed placements, probations Juvenile convictions History childhood neglect or sexual or physical victimization Witness domestic violence Antisocial father Deviant arousal on Penile Plethysmograph

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

Dynamic Risk Factors : Dynamic Risk Factors

Big Three…or Four : Big Three…or Four Substance Abuse Criminal Peers Criminal Cognitions Mental Illness

Negative, Antisocial, or Criminal Attitudes? : Negative, Antisocial, or Criminal Attitudes?

Substance Use : Substance Use Strong relationship with violence Increases odds of violence x10 (Swanson) Alcohol abuse 10-20x more common in homicide offenders relative to the general population (Eronen et al.) Co-morbid substance use is a greater risk factor for violence than any other mental illness

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Step-wise Progression: Context Behavioral Change Levels of Security Generalization of Skills Ideally, increments of decreased structure and increased skill and freedom

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style… the CMHIP Translation

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk High Risk? Intensive Treatment Low Risk? “Fast Track” Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

Recidivism: Comparing Risk Level and Treatment Intensity : Recidivism: Comparing Risk Level and Treatment Intensity

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk High Risk? Intensive Treatment Low Risk? “Fast Track” Treatment Pathways Security Levels and Privilege Sequence Need……Target criminogenic needs Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

Psychopathy : Psychopathy Criminal Personality

NGRI Treatment : NGRI Treatment Consider Psychopathy a Responsivity variable Interpersonal and affective characteristics make tx difficult Beware: therapist report of positive treatment alliance correlated with increased violence (Seto & Barbaree)

Tailor Treatment: : Tailor Treatment: Provide MORE! Cognitive Behavioral: Relapse Prevention! Target behavior change, not personality change: Risk Factors Appeal to self-interest Non-judgmentally expect lying

Principles of Effective Forensic Treatment: : Principles of Effective Forensic Treatment: Risk……Match level of service to level of risk Need……Target criminogenic needs… via the VRS Responsivity……tailor treatment to the consumer’s Stage of Change, cultural background, and learning style

VRS Dynamic Risk Factors : VRS Dynamic Risk Factors D1 Violent Lifestyle D2 Criminal Personality D3 Criminal Attitudes D4 Work Ethic D5 Criminal Peers D6 Interpersonal Aggression D7 Emotional Control

VRS Dynamic Risk Factors(continued) : VRS Dynamic Risk Factors(continued) D8 Violence during Institutionalization D9 Weapon Use D10 Insight into Violence D11 Mental Disorder D12 Substance Abuse D13 Stability of Relationships with Significant Others D14 Community Support

VRS Dynamic Risk Factors(continued) : VRS Dynamic Risk Factors(continued) D15 Released Back to High Risk Situations D16 Violence Cycle D17 Impulsivity D18 Cognitive Distortions D19 Compliance with Supervision D20 Security Level of Anticipated Release

Targetting Dynamic Risk Factors: : Targetting Dynamic Risk Factors: NGRI Patient must: Recognize the Problem Have Reason to Change Identify Skill Deficits Learn New Skills Practice New Skills Demonstrate New Skills Generalize New Skills

VRS Substance Abuse Treatment Planning : VRS Substance Abuse Treatment Planning Patient will: explore ways substances have increased and decreased his quality of life identify pros and cons of continued substance use attend and participate in DBT Skills Training learn and practice DBT Skills and successfully graduate from Basic DBT Skills Training Group practice skills in real life situations while using OFGS, OFGU, and living on Community Placement? Why we need YOU!!

VRS and Stages of Change : VRS and Stages of Change Precontemplation Contemplation Preparation Action Maintenance? Again, why we need YOU!

Principles of Forensic Treatment: Clinical Judgement…So… : Principles of Forensic Treatment: Clinical Judgement…So… Multiple Eyes: Team Risk Update Disposition Committee Superintendent “Denver” oversight Independent Consultants Attorneys and Court

Mock Direct Examination : Mock Direct Examination

Audience Participation ExerciseQuestions : Audience Participation ExerciseQuestions

Mock Cross Examination by DAAudience Participation ExerciseQuestionsTomorrow… : Mock Cross Examination by DAAudience Participation ExerciseQuestionsTomorrow…

Day 2 : Day 2 Risk Management

Risk Management : Risk Management Assessment is useless unless it is put to use A Comprehensive Release Plan Incorporates the Four S’s Scrutiny Support Services Structure

Support : Support Social networks reinforce prosocial versus risky behavior Satisfying relationships with clinicians (and others) correlated with treatment adherence and low risk of future violations Dislike of treatment provider correlated with future violations

Services:continue to… : Services:continue to… Target Dynamic Risk Factors

Comprensive Release Plan (continued) : Comprensive Release Plan (continued) Support Scrutiny Services Structure

Which patients are more risky upon discharge? : Which patients are more risky upon discharge? Forensic inpatients discharged from forensic inpatient units? or Civil inpatients discharged from civil inpatient units? Hint: Think about the 4S’s

CMHIP Forensic Community Based Services Programs : CMHIP Forensic Community Based Services Programs

When the NGRI patient progresses in treatment tocommunity residence … : When the NGRI patient progresses in treatment tocommunity residence … Forensic Community Based Services Provides Follow-up and Case Management Services.

“Community Placement” : “Community Placement” As to legal status: The Defendant remains a patient of CMHIP but lives off the hospital grounds, under statute allowing off-grounds privileges with court approval, usually in assisted living facility, with family, etc.

Community PlacementCourt Procedure : Community PlacementCourt Procedure Request for Community Placement, and proposed terms of placement, are sent to court by Superintendent; DA has 30 days to object; If no objection, approval is automatic; If there is an objection, the hospital may request a hearing.

Conditions of Community Placement“CP” : Conditions of Community Placement“CP” Issues addressed by the conditions include: Who will monitor the patient? Where will the patient reside? How will medication be monitored? Are substance abuse toxicology screens required? FCBS Can Require CP Patient to Return to Inpatient Care at any time, for any reason, and without Court action.

Conditional Release“CR” : Conditional Release“CR” Court has released the Defendant (patient) from his legal commitment to CDHS, Patient must comply with court-ordered conditions to remain on release status Generally, psych care and case management is provided by Mental Health Center, with reports to FCBS.

The CMHIP Comprehensive Release Plan : The CMHIP Comprehensive Release Plan “Requirements for Community Placement” Conditions of Release Support Scrutiny Services Structure

FCBS Drafts Court Order addressing: : FCBS Drafts Court Order addressing: Residence Mental Health Services Required Participation in Program Medication Home Visits/Searches Approved Employment and Activities Return to In-Patient Care Free Exchange of Information CMHIP and Center Contact with Family Weapons Prohibited Alcohol Use and Substance Abuse Prohibited Driver's License Reporting of Offenses Travel

Court finalizes and signs Order : Court finalizes and signs Order FCBS Provides an annual report to the Court regarding the Patient’s compliance with conditions set by the Court. FCBS notifies the Court of violations of the Court-Ordered conditions in report, and if serious, as soon as the violations are known to FCBS. If violations, the Court may issue an arrest warrant and return the Patient to jail or CDHS custody.

As of April 1 2010, FCBS follows: : As of April 1 2010, FCBS follows: 54 Patients on Community Placement status 98 Patients who are Conditionally Released from Commitment Counties of Residence Include: Adams, Denver, El Paso, Arapahoe, Fremont, Otero, Larimer, Weld, Mesa, Jefferson, Boulder, Pueblo, Garfield, Arapahoe and La Plata

Community Placement for ITP Defendants? : Community Placement for ITP Defendants? Although there are none at this time, Colorado statutes allow defendants who: (1) have been found Incompetent to Proceed in their criminal cases, and (2) are inpatients at a CDHS facility (usually, CMHIP-IFP) to move into the community on CP status, with court ordered conditions and with monitoring by FCBS.

FCBS Services Targeted at Risk Factors : FCBS Services Targeted at Risk Factors Utilizing the Recovery Model, promote patient independence and enhance community safety Individual Contacts: “check-ins”, therapy, crisis intervention Home Visits and Searches Group Therapy with focus on reinforcing skills to live in Community and sharing resources and experiences Medication teaching and assessment (benefits, side effects, interactions) Partnerships with Employers, School, Significant Others, and Family Assistance with obtaining benefits and other services (bus pass, food stamps) Hair analysis for substance abuse Assistance with developing and following budget Assistance with developing and updating Wellness Recovery Action Plan (WRAP) for relapse prevention and management plan.

Current Workload : Current Workload Each FCBS Case Manager is assigned 10-13 CP/CR patients (depending on acuity and county of residence) Each FCBS CR coordinator is assigned to approximately 45-50 CR patients (geographic distribution)

FCBS Personnel : FCBS Personnel Contacts: Linda Dotson (719-546-4498) FCBS Director Paula Yacconi (719-546-4823) FCBS Assistant Director Judy Gurule (719-546-4289) Court Liaison and Disposition Coordinator Christine Braun (719-546-4726) CR Coordinator 10 Case Managers, in Pueblo and Denver Offices FCBS Staff Psychiatrists: Elissa Ball, Gary Martz, Ken Locke FCBS Staff Psychologists: Nicole Mack and Pam Morgan

QuestionsMock Direct Examination of Your Expert (Risk Management) : QuestionsMock Direct Examination of Your Expert (Risk Management)

BreakAudience Participation Exercise : BreakAudience Participation Exercise

Case Presentation: a Successful Case : Case Presentation: a Successful Case

Final Questions : Final Questions