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RRP 12-507 – HSR&D Study

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RRP 12-507
Veterans Justice Programs: Improving Access to Mental Health Services
Daniel M. Blonigen PhD MA
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: February 2014 - January 2015

BACKGROUND/RATIONALE:
Up to 146,000 Veterans are released each year from state and federal prisons, and city and county jails. These "justice-involved Veterans" are a highly vulnerable group with a host of mental health problems and psychosocial impairments, which put them at risk to recidivate. The Veterans Justice Programs (VJP), comprising the Healthcare for Re-entry Veterans (HCRV) and Veterans Justice Outreach (VJO) programs, are relatively new VA initiatives. Through VJP Specialists who conduct outreach efforts with justice-involved Veterans, the goals of these programs are to promote the long-term recovery of justice-involved Veterans by increasing access to, and engagement with, mental health and other services in VA. To date, there have been no efforts to document variations in the practices and perspectives of VJP Specialists with respect to (a) assessment of recidivism risk (i.e., Structured Risk Assessments [SRAs]), or (b) the implementation potential of interventions that have been shown to reduce the risk of recidivism in this population (i.e., Moral Reconation Therapy [MRT]; Thinking 4 Change [T4C]). Such efforts would facilitate the goal of VJP national leaders of moving toward implementation of empirically-supported interventions to address recidivism risk among justice-involved Veterans.

OBJECTIVE(S):
To address the goals of our operational partners in VJP, the objective of this project was to obtain information on the practices and perspectives of VJP Specialists with regard to the assessment and treatment of recidivism risk among justice-involved Veterans. To help structure our inquiry, we utilized the Risk-Need-Responsivity (RNR) model, a conceptual framework that outlines the principles that facilitate the successful community reintegration of justice-involved individuals. Our aims were two-fold:

Aim 1: Among VJP Specialists, identify their awareness of, beliefs about, and decision-making practices with justice-involved Veterans in terms of risk factors of recidivism that are highlighted in the RNR model.

Aim 2: Evaluate the implementation potential of RNR-based "best" practices with justice-involved Veterans including SRAs and cognitive-behavioral interventions for criminogenic thinking (e.g., MRT, T4C).

METHODS:
Semi-structured, qualitative interviews were conducted by telephone with 63 VJP Specialists nationwide, including three randomly selected specialists from each VISN (41 VJO, 13 HCRV, and 9 Dual providers). The study interview guide comprised three sections: (i) questions regarding whether, and how, Specialists addressed risk factors for recidivism among justice-involved Veterans. This section included discussion of risk factors identified a priori in the RNR model (e.g., substance abuse; lack of employment/employment skills; criminogenic thinking); as well as other risk factors that were identified by the Specialists; (ii) questions regarding knowledge and use of structured risk assessments (SRAs); and (ii) questions regarding knowledge and use of evidence-based treatments for criminogenic thinking. Interview transcripts were coded in ATLAS.ti using template analysis, and qualitative pile-sorting was conducted by members of the project team to identify emergent themes in the textual data.

FINDINGS/RESULTS:
To date, we have three main sets of findings, which correspond to the aforementioned sections of the interview guide. Manuscripts are currently in preparation; however, some analyses are ongoing, and therefore the findings reported below are preliminary.

The first set of findings pertain to the Specialists' perceptions of the (a) primary risk factors for recidivism among justice-involved Veterans, and (b) availability of treatment options in VA to address these risk factors in this population. The most commonly reported risk factors were substance (83%), housing problems (59%), employment/financial problems (44%), limited family/social support (41%), and mental illness (41%). Specialists reported that justice-involved Veterans generally have access to treatments and services for these risk factors, but have less access to treatments in VHA that directly target "criminogenic" thinking, which is a key risk factor for recidivism identified in the RNR model. These findings suggest that treatment of criminogenic thinking may be a significant gap in the implementation of best practices to reduce recidivism among justice-involved Veterans, and call for more systematic efforts in VA to implement such interventions.

The second set of findings pertains to the Specialists knowledge and use of SRAs. A total of 62% of Specialists (58% VJO, 62% HCRV, and 78% Dual) indicated that SRAs were used in some way to measure recidivism risk with the Veterans under their care. A minority of Specialists (18%) reported administering SRAs themselves or seeing the results of SRAs conducted by other justice personnel. Despite limited use, 73% of Specialists indicated that SRAs were (or would be) helpful in their work with justice-involved Veterans, specifically for assistance with triage, case management, treatment planning, and advocacy reasons. Additionally, 90% of Specialists expressed an interest in further training on SRA use. Qualitative analyses have thus far identified four perceived barriers to implementation of SRAs in VA: (1) constraints on providers' time and resources; (2) potential stigma or denial of services for "high-risk" Veterans; (3) negative impact on alliance with Veterans; and (4) misinterpretation or misuse of assessment results. These findings suggest that integration of SRAs may also be a significant gap in the implementation of best practices to reduce recidivism among justice-involved Veterans. To facilitate such integration, health care settings should educate VJP Specialists, and other VA providers who serve justice-involved Veterans, on proper use and interpretation of SRAs, and develop brief SRAs that complement (rather than add to) existing assessments conducted by VJP Specialists.

The third set of findings pertains to the Specialists knowledge and use of evidence-based treatments for criminogenic thinking (i.e., MRT; T4C). Out of the total sample, 43% (n=27) reported training or experience in either MRT or T4C. Nineteen Specialists reported being trained in MRT, eight of whom were currently running or had previously run an MRT group. An additional 6 individuals reported that MRT was being provided to justice-involved Veterans by other agencies and in other settings outside VA (e.g., Veterans Treatment Courts). Regarding T4C, 8 Specialists reported experience with this intervention (5 of whom were formally trained; 2 reported currently using T4C). Currently, we are using Glasgow and colleagues' (1999) Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify perceived barriers and facilitators to implementation of MRT or T4C. Initial thematic coding has indicated that (a) it may be useful to have Veterans who had successfully completed MRT or T4C to serve as peer supports for justice-involved Veterans who are beginning these interventions, (b) longer-term residential mental health programs may be ideal settings in which to implement MRT in VA, and (c) national calls or workgroups, particularly following initial training in MRT, may facilitate treatment fidelity and long-term maintenance of the intervention at specific sites.

IMPACT:
Knowledge gained from the proposed project informed the development of a recently-funded HSR&D proposal to conduct an effectiveness trial with justice-involved Veterans by suggesting, for example, that the ideal treatment setting in which to implement the intervention would be residential homeless programs. The proposed project has also spurred efforts at establishing (a) a workgroup to support VJP Specialists who are currently running, or considering implementing, MRT groups at their local sites, and (b) a coordinated program evaluation of MRT groups in VA. Collectively, these impacts have helped to address the goals of the VJP of moving toward implementation of empirically-supported interventions to address recidivism risk among the highly-vulnerable, and growing, population of justice-involved Veterans.

PUBLICATIONS:

Journal Articles

  1. Rodriguez AL, Manfredi L, Wong AC, Nevedal A, Timko C, Rosenthal J, Blonigen DM. Implementation Potential of Structured Risk Assessments for Criminal Recidivism in the Veterans Health Administration: Qualitative Perspectives From Providers. Criminal justice policy review. 2017 Aug 14; DOI: https://doi.org/10.1177/0887403417725567 .
  2. Blonigen DM, Rodriguez AL, Manfredi L, Nevedal A, Rosenthal J, McGuire JF, Smelson D, Timko C. Cognitive-behavioral treatments for criminogenic thinking: Barriers and facilitators to implementation within the Veterans Health Administration. Psychological Services. 2018 Feb 1; 15(1):87-97.
  3. Blonigen DM, Rodriguez AL, Manfredi LB, Britt J, Nevedal A, Finlay AK, Rosenthal J, Smelson D, Timko C. The availability and utility of services to address risk factors for recidivism among justice-involved veterans. Criminal justice policy review. 2016 Feb 10; DOI: 10.1177/0887403416628601.
  4. Glynn LH, Kendra MS, Timko C, Finlay AK, Blodgett JC, Maisel NC, Midboe AM, McGuire JF, Blonigen DM. Facilitating treatment access and engagement for justice-involved Veterans with substance use disorders. Criminal justice policy review. 2016 Feb 4; 27(2):doi: 10.1177/0887403414560884.
  5. Timko C, Midboe AM, Maisel NC, Blodgett JC, Asch SM, Rosenthal J, Blonigen DM. Treatments for recidivism risk among justice-involved Veterans. Journal of offender rehabilitation. 2014 Nov 5; 53(8):620-640.
Book Chapters

  1. Blonigen DM, Wytiaz A. Multimethod assessment of the adult externalizing spectrum: Disorders of antisocial behavior and substance use. In: Hopwood CJ, Bornstein RF, editors. Multimethod Clinical Assessment. New York, NY: The Guilford Press; 2014. Chapter 7. 203-231 p.
Conference Presentations

  1. Rodriguez A, Manfredi L, Nevedal A, Rosenthal J, Blonigen DM. Implementation potential of structured recidivism risk assessments with justice-involved Veterans: Qualitative perspectives from providers. Paper presented at: Society for Implementation Research Collaboration Biennial Conference on Advancing Efficient Methodologies Through Community Partnerships and Team Science; 2015 Sep 25; Seattle, WA.
  2. Blonigen DM, Rodriguez A, Nevedal A, Smelson D, Finlay A, Rosenthal J, Timko C. A Qualitative Analysis to Identify Provider Perceptions of Gaps in the Implementation of Best Care Practices to Reduce Recidivism among Justice-Involved Veterans. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  3. Blonigen DM, Rodriguez A, Manfredi L, Timko C. Gaps in the implementation of best-care practices to improve outcomes among justice-involved Veterans: A qualitative analysis. Presented at: AcademyHealth Behavioral Health Services Research Interest Group Meeting; 2015 Jun 13; Minneapolis, MN.
  4. Blonigen DM. Challenges to implementing evidence-based practices in VA to reduce recidivism among justice-involved Veterans. Paper presented at: Association for Criminal Justice Research (California) Semi-Annual Meeting; 2015 Mar 27; McClellan, CA.
  5. Blonigen DM, Bui L, Britt JY. Personality, mental health, and substance abuse treatment outcomes among Veterans with a history of criminal justice involvement. Paper presented at: American Society of Criminology Annual Meeting; 2014 Nov 19; San Francisco, CA.
  6. Britt J, Bui L, Blonigen DM. Personality differences and impact on perceptions of the treatment milieu among Veterans with a history of criminal justice involvement. Poster session presented at: American Society of Criminology Annual Meeting; 2014 Nov 19; San Francisco, CA.
  7. Rodriguez A, Blonigen DM. Practices and perspectives of Veterans Justice Program (VJP) Specialists. Paper presented at: VA Ci2i / NCPTSD / HERC Annual Research Assistant Conference; 2014 May 21; Menlo Park, CA.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Prevention
Keywords: QUERI Implementation
MeSH Terms: none