Supervising Offenders and Defendants with Mental Health Disorders

SUPERVISING OFFENDERSSUPERVISING OFFENDERS
AND DEFENDANTS WITHAND DEFENDANTS WITH
MENTAL HEALTH DISORDERSMENTAL HEALTH DISORDERS
Developed by:Developed by:
Aaron WonnemanAaron Wonneman

Training ObjectivesTraining Objectives
 Review myths and facts about mental health
 Define a mental health disorder
 Identify common diagnoses and symptoms associated
with various mental health disorders
 Discuss frequently prescribed psychotropic medications
 Review research on specialized caseloads
 Discuss evidence-based supervision strategies and
case planning for effective supervision

Facts and Myths about MentalFacts and Myths about Mental
HealthHealth
 Mental Illness is a rare condition that only affects a smallMental Illness is a rare condition that only affects a small
percentage of the populationpercentage of the population
 AnswerAnswer: MYTH: MYTH
 Facts:Facts:
 1 in 5 America adults have experienced a mental health issue1 in 5 America adults have experienced a mental health issue
 1 in 10 young people experienced a period of major depression1 in 10 young people experienced a period of major depression
 1 in 25 Americans live with a serious mental illness such as depression, schizophrenia, bipolar1 in 25 Americans live with a serious mental illness such as depression, schizophrenia, bipolar
disorder, or major depressiondisorder, or major depression
 *According to U.S. Department of Health and Mental Hygiene (mentalhealth.gov)*According to U.S. Department of Health and Mental Hygiene (mentalhealth.gov)
 Individuals with mental illness areIndividuals with mental illness are more likelymore likely to committo commit
violence than those without a mental health disorderviolence than those without a mental health disorder
 Facts:Facts:
 The vast majority of people with mental illness are no more likely to be violent than anyoneThe vast majority of people with mental illness are no more likely to be violent than anyone
else.else.
 Only 3%-5% of violent acts can be attributed to individuals living with serious mental illnessOnly 3%-5% of violent acts can be attributed to individuals living with serious mental illness
 People with severe mental illness are 10 timesPeople with severe mental illness are 10 times more likely to bemore likely to be victimsvictims of violent crimesof violent crimes
than the general populationthan the general population

Facts and Myths (cont.)Facts and Myths (cont.)
 Mental illness is caused by personalMental illness is caused by personal
weakness or lack of motivation to changeweakness or lack of motivation to change
 Facts:Facts:
 Similar to heart disease and diabetes, mental illness is aSimilar to heart disease and diabetes, mental illness is a
legitimate medical issuelegitimate medical issue
 Just like any major illness, mental illness isJust like any major illness, mental illness is notnot thethe faultfault
of the person with the condition. Mental illness is oftenof the person with the condition. Mental illness is often
the result of environment and biological factors outside ofthe result of environment and biological factors outside of
the individual’s controlthe individual’s control
 National Alliance on Mental Illness (nami.org)National Alliance on Mental Illness (nami.org)

Fact and MythsFact and Myths
 Over half of individuals in the U.S. who experience aOver half of individuals in the U.S. who experience a
substance use disorder also have a mental illnesssubstance use disorder also have a mental illness
 AnswerAnswer: FACT: FACT
 Among the 20.2 million adults in the U.S. who experience substanceAmong the 20.2 million adults in the U.S. who experience substance
use disorder, 10.2 million (50.5%) had a co-occurring mental illnessuse disorder, 10.2 million (50.5%) had a co-occurring mental illness
 SAMSA, Results from the 2014 National Survey on Drug Use and HealthSAMSA, Results from the 2014 National Survey on Drug Use and Health
 PeoplePeople cancan recover from mental illnessrecover from mental illness
 AnswerAnswer: FACT: FACT
 Although some chronic conditions may never be completelyAlthough some chronic conditions may never be completely
“cured”, recovery is possible for many individuals with mental“cured”, recovery is possible for many individuals with mental
illnessillness
 Recovery may mean the absence of all mental health symptoms OR simplyRecovery may mean the absence of all mental health symptoms OR simply
the ability to live a fulfilling life despite the mental health conditionthe ability to live a fulfilling life despite the mental health condition

Definition of Mental IllnessDefinition of Mental Illness
 A Mental Illness is a health condition whichA Mental Illness is a health condition which
causescauses changes in thinking, emotion,changes in thinking, emotion,
behavior, or moodbehavior, or mood (or a combination of(or a combination of
these).these).
 Mental health disturbances generally qualifyMental health disturbances generally qualify
as a “disorder” if the individual experiences:as a “disorder” if the individual experiences:
 Marked distress, impairment, and/or problemsMarked distress, impairment, and/or problems
functioning in social, work, or family activities.functioning in social, work, or family activities.
 American Psychiatric Association (psychiatry.org)American Psychiatric Association (psychiatry.org)

Diagnostic and Statistical Manual ofDiagnostic and Statistical Manual of
Mental Health Disorders, Fifth EditionMental Health Disorders, Fifth Edition
(DSM-5)(DSM-5)
 The standard classification of mental disorders used by mentalThe standard classification of mental disorders used by mental
health professionals in the U.S.health professionals in the U.S.
 DSM-5 was released in 2013 and consists of three majorDSM-5 was released in 2013 and consists of three major
components:components:
1.1. Diagnostic ClassificationDiagnostic Classification
 The official list of mental disorders recognized by the U.S. healthcare systemThe official list of mental disorders recognized by the U.S. healthcare system
1.1. Diagnostic Criteria SetsDiagnostic Criteria Sets
 Indicates a list of symptoms that must be present (and for how long) for eachIndicates a list of symptoms that must be present (and for how long) for each
conditioncondition
1.1. Descriptive TextDescriptive Text
 Provides additional information on each disorder including:Provides additional information on each disorder including:
 Diagnostic features, Subtypes or Specifiers, Prevalence, Culture/Gender-relatedDiagnostic features, Subtypes or Specifiers, Prevalence, Culture/Gender-related
issuesissues

Common Mental HealthCommon Mental Health
DisordersDisorders
 Anxiety DisordersAnxiety Disorders
 Mood DisordersMood Disorders
 Schizophrenia and Psychotic DisordersSchizophrenia and Psychotic Disorders
 Trauma and Stressor-related DisordersTrauma and Stressor-related Disorders
 Personality DisordersPersonality Disorders

Anxiety DisorderAnxiety Disorder
 Excessive fear or anxiety that is difficult toExcessive fear or anxiety that is difficult to
control and negatively and substantiallycontrol and negatively and substantially
impacts daily functioning.impacts daily functioning.
 Fear is the emotional response to a real or perceived threat.Fear is the emotional response to a real or perceived threat.
 Anxiety is the anticipation of a future threatAnxiety is the anticipation of a future threat
 Nearly 40 million people in the U.S. (18%)Nearly 40 million people in the U.S. (18%)
experience an anxiety disorder in anyexperience an anxiety disorder in any
given year.given year.

Mood DisordersMood Disorders
 Common mood disorders include:Common mood disorders include:
 Major Depressive Disorder; andMajor Depressive Disorder; and
 Bipolar DisorderBipolar Disorder

Major Depressive DisorderMajor Depressive Disorder
(MDD)(MDD)
 MDD is defined as having a depressed mood for most ofMDD is defined as having a depressed mood for most of
the day and a diagnosis requires daily symptoms for athe day and a diagnosis requires daily symptoms for a
two-week period.two-week period.
 Depressive disorders are among the most commonDepressive disorders are among the most common
mental health disorders in the U.S.mental health disorders in the U.S.
 It’s estimated that 6.6% of adults suffer from MDD.It’s estimated that 6.6% of adults suffer from MDD.
 CausesCauses: genetic, biological and environmental factors.: genetic, biological and environmental factors.

Bipolar DisorderBipolar Disorder
 A chronic mental illness defined byA chronic mental illness defined by dramatic shiftsdramatic shifts in ain a
person’s mood, energy, and the ability to think clearlyperson’s mood, energy, and the ability to think clearly
and rationallyand rationally
 Affects approximatelyAffects approximately 5.7 million5.7 million adult Americans oradult Americans or
about 2.5% of the populationabout 2.5% of the population
 Equally impacts men and womenEqually impacts men and women
 More than two-thirds of people with bipolar disorder haveMore than two-thirds of people with bipolar disorder have
at least oneat least one close relative with the illness and/or majorclose relative with the illness and/or major
depressiondepression

Bipolar Disorder: SymptomsBipolar Disorder: Symptoms
ManiaMania
 Heightened mood, exaggeratedHeightened mood, exaggerated
optimism, and self-confidenceoptimism, and self-confidence
 Decreased need for sleep (lessDecreased need for sleep (less
than 3 hours) without fatiguethan 3 hours) without fatigue
 Inflated sense of self-Inflated sense of self-
importanceimportance
 Excessive irritability, aggressiveExcessive irritability, aggressive
behaviorbehavior
 Racing speech or flight of ideasRacing speech or flight of ideas
 Reckless and impulsiveReckless and impulsive
behavior without concern forbehavior without concern for
safety or consequencessafety or consequences
 Spending sprees, erratic driving,Spending sprees, erratic driving,
sexual indiscretionssexual indiscretions
DepressionDepression
 Prolonged sadness,Prolonged sadness,
unexplained crying spellsunexplained crying spells
 Significant changes in appetiteSignificant changes in appetite
and sleep patternsand sleep patterns
 Loss of energy, persistentLoss of energy, persistent
tirednesstiredness
 Feelings of guilt orFeelings of guilt or
worthlessnessworthlessness
 Inability to concentrate,Inability to concentrate,
indecisivenessindecisiveness
 Thoughts of death or suicideThoughts of death or suicide
 Reference: Depression and Bipolar Support Alliance (DBSA)Reference: Depression and Bipolar Support Alliance (DBSA)

Psychotic Spectrum Disorders:Psychotic Spectrum Disorders:
SchizophreniaSchizophrenia
 SchizophreniaSchizophrenia is a chronic and severe mental disorderis a chronic and severe mental disorder
that affects how a person thinks, feels, and behavesthat affects how a person thinks, feels, and behaves
 ApproximatelyApproximately 3.5 million people3.5 million people in the U.S. are diagnosedin the U.S. are diagnosed
with Schizophrenia and it is one of thewith Schizophrenia and it is one of the leading causes ofleading causes of
disabilitydisability
 Most cases are diagnosedMost cases are diagnosed between 16 and 25 years of agebetween 16 and 25 years of age
 Reference: National Institute of Mental Health (nimh.nih.gov)Reference: National Institute of Mental Health (nimh.nih.gov)

Schizophrenia:Schizophrenia:
Signs and SymptomsSigns and Symptoms
 Delusions:Delusions:
 Delusions of PersecutionDelusions of Persecution
 A person feels unreasonably suspicious of othersA person feels unreasonably suspicious of others
 Individuals often express bizarre ideas or plots that others are “out toIndividuals often express bizarre ideas or plots that others are “out to
get” themget” them
 ““The government is poisoning the water supply.”The government is poisoning the water supply.”
 ““An FBI car has been following me all week.”An FBI car has been following me all week.”
 Delusions of ReferenceDelusions of Reference
 Neutral events are believed to have personal meaning to the individualNeutral events are believed to have personal meaning to the individual
 ““The television reporter is talking directly to me / sending me messages.”The television reporter is talking directly to me / sending me messages.”
 ““That song lyric was written for me.”That song lyric was written for me.”
 Reference: Schizophrenia and Related Disorders Alliance of America (SARDAA.org)Reference: Schizophrenia and Related Disorders Alliance of America (SARDAA.org)

Signs and Symptoms (Cont)Signs and Symptoms (Cont)
 Delusions of GrandeurDelusions of Grandeur
 Belief that one is famous, important, or all-knowing. Belief that oneBelief that one is famous, important, or all-knowing. Belief that one
has special powershas special powers
 ““I can read your mind.”I can read your mind.”
 ““I am God.”I am God.”
 Delusions of ControlDelusions of Control
 Belief that one’s thoughts or actions are being controlled by anBelief that one’s thoughts or actions are being controlled by an
outside forceoutside force
 Thought Broadcasting:Thought Broadcasting:
 ““My thoughts are being transmitted to others through theMy thoughts are being transmitted to others through the
radio.”radio.”
 Thought Insertion:Thought Insertion:
 ““The CIA put a chip in my body that controls my thoughts.”The CIA put a chip in my body that controls my thoughts.”
 Thought Withdraw:Thought Withdraw:
 ““Government agents are stealing my thoughts.”Government agents are stealing my thoughts.”

Signs and Symptoms (cont)Signs and Symptoms (cont)
 HallucinationsHallucinations
 Auditory are most commonAuditory are most common
 Visual (Sight)Visual (Sight)
 Olfactory (Smell)Olfactory (Smell)
 Gustatory (Tasting)Gustatory (Tasting)
 Tactile (Feeling)Tactile (Feeling)

Signs and Symptoms (Cont)Signs and Symptoms (Cont)
 Disorganized Speech and/or thoughtDisorganized Speech and/or thought
processprocess
 Looseness of AssociationsLooseness of Associations: Lack of clarity between one: Lack of clarity between one
thought to nextthought to next
 Circumstantial SpeechCircumstantial Speech: Inclusion of non-essential details: Inclusion of non-essential details
in responsein response
 Tangential SpeechTangential Speech: Loss of goal-directed speech / failure: Loss of goal-directed speech / failure
to address the original point or questionto address the original point or question
 PerseverationPerseveration: Repetition of a single word or phrase over: Repetition of a single word or phrase over
and overand over
 Disorganized behavior or lack ofDisorganized behavior or lack of
expressiveness (i.e. ‘flat affect’)expressiveness (i.e. ‘flat affect’)

Trauma and Stressor-RelatedTrauma and Stressor-Related
DisordersDisorders
 Post-Traumatic Stress Disorder (PTSD)Post-Traumatic Stress Disorder (PTSD)
 Characterized by the development ofCharacterized by the development of
debilitating symptoms following exposure to adebilitating symptoms following exposure to a
traumatic or dangerous event.traumatic or dangerous event.
 Occurs from re-experiencing symptoms, such asOccurs from re-experiencing symptoms, such as
flashbacks or migraines, avoidance symptoms, orflashbacks or migraines, avoidance symptoms, or
being hyper-aroused and these make daily tasksbeing hyper-aroused and these make daily tasks
nearly impossible.nearly impossible.
 First identified in soldiers returning from combat,First identified in soldiers returning from combat,
but can also occur in violent neighborhoods,but can also occur in violent neighborhoods,
abusive households, prison, etc.abusive households, prison, etc.

PTSD (cont)PTSD (cont)
 Diagnosis must be preceded by exposureDiagnosis must be preceded by exposure
to actual or threatened death, seriousto actual or threatened death, serious
injury, or violence.injury, or violence.
 War, sexual assault, natural disasters, carWar, sexual assault, natural disasters, car
accident, child abuse…accident, child abuse…
 Estimated that 7.7 million people in the U.S.Estimated that 7.7 million people in the U.S.
have PTSD.have PTSD.
 Women are more likely to have the disorderWomen are more likely to have the disorder
when compared to men.when compared to men.

Personality DisordersPersonality Disorders
 An enduring pattern of inner experienceAn enduring pattern of inner experience
and behavior that deviates markedly fromand behavior that deviates markedly from
the expectations of the culture of thethe expectations of the culture of the
individual who exhibits it (DSM).individual who exhibits it (DSM).
 Two Common:Two Common:
 Antisocial Personality DisorderAntisocial Personality Disorder
 Borderline Personality DisorderBorderline Personality Disorder

Antisocial Personality DisorderAntisocial Personality Disorder
 A pervasive pattern of disregard for, and violation of, theA pervasive pattern of disregard for, and violation of, the
rights of others that begins in childhood or early adolescencerights of others that begins in childhood or early adolescence
and continues through adulthood (DSM)and continues through adulthood (DSM)
 People with this disorder are frequently involved in thePeople with this disorder are frequently involved in the
criminal justice systemcriminal justice system
 Common behaviors include:Common behaviors include:
 Disregard for societal rules, norms, or laws / consequencesDisregard for societal rules, norms, or laws / consequences
 Low tolerance for discomfort or frustrationLow tolerance for discomfort or frustration
 Repeatedly lying and blaming othersRepeatedly lying and blaming others
 Placing others at risk for their own benefitPlacing others at risk for their own benefit
 Profound lack of empathy, remorse, or connection with othersProfound lack of empathy, remorse, or connection with others
 Reference: PsychCentral.comReference: PsychCentral.com

Borderline Personality DisorderBorderline Personality Disorder
(BPD)(BPD)
 Characterized by difficulty in regulating emotion. This difficulty leadsCharacterized by difficulty in regulating emotion. This difficulty leads
to severe, unstable mood swings, impulsivity and instability, poorto severe, unstable mood swings, impulsivity and instability, poor
self-image, and stormy personal relationshipsself-image, and stormy personal relationships
 Estimated that 1.6% of US Population has BPD; nearly 75% areEstimated that 1.6% of US Population has BPD; nearly 75% are
womenwomen
 Reference: National Alliance on Mental Illness (NAMI)Reference: National Alliance on Mental Illness (NAMI)
 Individuals may make repeated attempts to avoid real or imaginedIndividuals may make repeated attempts to avoid real or imagined
abandonmentabandonment
 May manifest in behavior such as self-harm or suicide attemptsMay manifest in behavior such as self-harm or suicide attempts

BPD: SymptomsBPD: Symptoms
 Intense fear of abandonment, even going to extreme measures to avoidIntense fear of abandonment, even going to extreme measures to avoid
real or imagined separation or rejectionreal or imagined separation or rejection
 A pattern of unstable, intense relationshipsA pattern of unstable, intense relationships
 Idealizing someone one moment and then suddenly believing the personIdealizing someone one moment and then suddenly believing the person
doesn't care enough or is crueldoesn't care enough or is cruel
 Rapid changes in self-identity and self-image that include shifting goalsRapid changes in self-identity and self-image that include shifting goals
and values, and seeing yourself as bad or unwantedand values, and seeing yourself as bad or unwanted
 Impulsive and risky behavior, such as gambling, reckless driving,Impulsive and risky behavior, such as gambling, reckless driving,
unsafe sex, spending sprees, binge eating or drug abuse, or sabotagingunsafe sex, spending sprees, binge eating or drug abuse, or sabotaging
success by suddenly quitting a good job or ending a positivesuccess by suddenly quitting a good job or ending a positive
relationshiprelationship
 Self-Injury and suicidal threats are commonSelf-Injury and suicidal threats are common
Reference: Mayo Clinic (MayoClinic.org)Reference: Mayo Clinic (MayoClinic.org)

Signs of DecompensationSigns of Decompensation
 Physical SignsPhysical Signs::
 Changes in eating and sleepingChanges in eating and sleeping
behaviorbehavior
 Weight gain or lossWeight gain or loss
 Increased fatiguedIncreased fatigued
 Change in grooming habitsChange in grooming habits
 Behavioral SignsBehavioral Signs::
 Missed work, school, or therapyMissed work, school, or therapy
appointmentsappointments
 Loss of interest in hobbiesLoss of interest in hobbies
 Lack of engagement withLack of engagement with
family / social contactsfamily / social contacts
 Use of Drugs and alcoholUse of Drugs and alcohol
 Mood changesMood changes
 Emotional SignsEmotional Signs::
 Reduced self-esteemReduced self-esteem
 Feelings of guiltFeelings of guilt
 Lack of self-confidenceLack of self-confidence
 Suicidal thoughtsSuicidal thoughts
 Uncontrollable cryingUncontrollable crying
For all areas:For all areas:
 Consider any change inConsider any change in baselinebaseline
behavior and functioningbehavior and functioning
 If decompensation is evident,If decompensation is evident,
therapeutic intervention istherapeutic intervention is
necessarynecessary
Decompensation: Deterioration of an individual’s mental health and wellness

Psychotropic MedicationPsychotropic Medication
 Psychotropic medicationsPsychotropic medications affect brain chemicalsaffect brain chemicals
associated with mood and behaviorassociated with mood and behavior
 Just as individuals with diabetes may need insulinJust as individuals with diabetes may need insulin
to remain healthy, those with mental healthto remain healthy, those with mental health
disorders are often prescribed psychotropicdisorders are often prescribed psychotropic
medication to maintain wellnessmedication to maintain wellness
 Although there are benefits, many medicationsAlthough there are benefits, many medications
also have concerning side-effects; therefore, it isalso have concerning side-effects; therefore, it is
important for individuals to consult with mentalimportant for individuals to consult with mental
health professionals on a regular basis tohealth professionals on a regular basis to
determine effectivenessdetermine effectiveness

Common PsychotropicCommon Psychotropic
Medications:Medications:
AntidepressantsAntidepressants
 It is estimated that 11% of Americans (age 12 and older) areIt is estimated that 11% of Americans (age 12 and older) are
prescribed an anti-depressant medicationprescribed an anti-depressant medication
 Anti-depressants areAnti-depressants are the most common prescriptionthe most common prescription amongamong
adults age 18-44adults age 18-44
 Commonly used to treat depression, but can also beCommonly used to treat depression, but can also be
prescribed for other health conditions such as anxiety, pain,prescribed for other health conditions such as anxiety, pain,
and insomniaand insomnia
 The most common type of antidepressants are calledThe most common type of antidepressants are called
Selective Serotonin Reuptake Inhibitors (SSRIs)Selective Serotonin Reuptake Inhibitors (SSRIs) Reference: Centers for Disease Control (CDC)Reference: Centers for Disease Control (CDC)

SSRIsSSRIs
 SerotoninSerotonin is a neurotransmitter linked to many functions within the bodyis a neurotransmitter linked to many functions within the body
(i.e. mood, sleep, appetite, etc).(i.e. mood, sleep, appetite, etc).
 Many researchers believe that an imbalance in serotonin levels contributes to symptoms ofMany researchers believe that an imbalance in serotonin levels contributes to symptoms of
depressiondepression
 SSRI’s seek to correct the imbalance by blocking the “uptake” of serotonin in the pre-synapticSSRI’s seek to correct the imbalance by blocking the “uptake” of serotonin in the pre-synaptic
nervenerve
 Examples of SSRI’sExamples of SSRI’s::
 Prozac (Fluoxetine)Prozac (Fluoxetine)
 Celexa (Citalopram)Celexa (Citalopram)
 Zoloft (Sertraline)Zoloft (Sertraline)
 Paxil (Paroxetine)Paxil (Paroxetine)
 Lexapro (Escitalopram)Lexapro (Escitalopram)
 Side effectsSide effects::
 Drowsiness, nausea, dry mouth, dizziness, headaches, reduced libido, diarrhea,Drowsiness, nausea, dry mouth, dizziness, headaches, reduced libido, diarrhea,
blurred visionblurred vision
 Important noteImportant note: SSRIs are: SSRIs are slow actingslow acting medications that often take 4-6medications that often take 4-6
weeks for therapeutically significant effectsweeks for therapeutically significant effects

Antipsychotic MedicationAntipsychotic Medication
 Antipsychotic medications target several neurotransmitters including:
dopamine, serotonin, noradrenaline and acetylcholine.
 Dopamine is the main neurotransmitter targeted by anti-psychotics
 Helps control the brain’s reward and pleasure centers
 Regulates movement and emotional responses
 Dopamine deficiency results in Parkinson’s Disease
 Dopamine theory: Psychosis is due, in part, to an overactive dopamine system
 Antipsychotic medications, in part, seek to block dopamine receptors thus
suppressing:
 Hallucinations (such as hearing voices)
 Delusions (having ideas not based on reality)
 Thought disorders
 Extreme mood swings that are associated with bipolar disorder
 Older or first-generation antipsychotic medications are also calledOlder or first-generation antipsychotic medications are also called
conventional "conventional "typicaltypical" antipsychotics or “neuroleptics”. Some of the common" antipsychotics or “neuroleptics”. Some of the common
“typical” antipsychotics include:“typical” antipsychotics include:
 Thorazine (Chlorpromazine)Thorazine (Chlorpromazine)
 Haldol (Haloperidol)Haldol (Haloperidol)

Anti-psychotic medicationAnti-psychotic medication
(Cont)(Cont) Newer or second generation medications are also calledNewer or second generation medications are also called
""atypicalatypical" antipsychotics. Common atypical antipsychotics" antipsychotics. Common atypical antipsychotics
include:include:
 Risperdal (Risperidone)Risperdal (Risperidone)
 Zyprexa (Olanzapine)Zyprexa (Olanzapine)
 Seroquel (Quetiapine)Seroquel (Quetiapine)
 Abilify (Aripiprazole)Abilify (Aripiprazole)
 Geodon (Ziprasidone)Geodon (Ziprasidone)
 Several atypical antipsychotics are also used for treating bipolar depression or
depression associated with other mood disorders.
 Reference: National Institute of Mental Health
 Certain symptoms, such as feeling agitated and havingCertain symptoms, such as feeling agitated and having
hallucinations, usually go away within days of starting anhallucinations, usually go away within days of starting an
antipsychotic medicationantipsychotic medication
 Symptoms like delusions usually go away within a few weeks, but the
full effects of the medication may not be seen for up to six weeks.
 Every patient responds differently, so it may take several trials of
different antipsychotic medications to find the one that works best.

Anti-psychotics (cont)Anti-psychotics (cont)
 Side Effects:Side Effects:
 Typical (older) antipsychotic medications can cause
concerning side effects related to physical movement,
such as:
 Rigidity
 Persistent muscle spasms
 Tremors
 Restlessness
 Long-term use of typical antipsychotic medications may lead to a
condition called tardive dyskinesia (TD).
 Atypical (newer) antipsychotics generally have less risk of
side effects, but still may cause:
 Drowsiness, dizziness, restlessness, weight gain, dry mouth,
constipation, uncontrollable movements / tics / tremors, low
white blood-cell counts, nausea, blurred vision, and low blood
pressure
 Reference: National Institute of Mental Health

Mood StabilizersMood Stabilizers
 Used primarily to treat bipolar disorder, mood swingsUsed primarily to treat bipolar disorder, mood swings
associated with other mental disorders and also toassociated with other mental disorders and also to
augment the effect of other medications used to treataugment the effect of other medications used to treat
depression.depression.
 Mood Stabilizers work by decreasing abnormal activity inMood Stabilizers work by decreasing abnormal activity in
the brainthe brain

Mood StabilizersMood Stabilizers
 ExamplesExamples::
 Depakote (Divalproex Sodium)Depakote (Divalproex Sodium)
 Lithium (Lithobid)Lithium (Lithobid)
 Lamictal (Lamotrigine)Lamictal (Lamotrigine)
 Tegretol (Carbamazepine)Tegretol (Carbamazepine)
 Side EffectsSide Effects::
 Abnormal thinking, Uncontrollable shaking, Loss of coordination,Abnormal thinking, Uncontrollable shaking, Loss of coordination,
Uncontrollable eye movement, Blurred or double vision, RingingUncontrollable eye movement, Blurred or double vision, Ringing
in the ears, Hair loss, Mood swings, Drowsiness, Dizziness,in the ears, Hair loss, Mood swings, Drowsiness, Dizziness,
Headache, Diarrhea, Constipation, Changes in appetiteHeadache, Diarrhea, Constipation, Changes in appetite

Anti-Anxiety MedicationAnti-Anxiety Medication
 Help reduce the symptoms of anxiety, such asHelp reduce the symptoms of anxiety, such as
panic attacks, or extreme fear and worry.panic attacks, or extreme fear and worry.
 Most common med: Benzodiazepines.Most common med: Benzodiazepines.
 Klonopin (Clonazepam)Klonopin (Clonazepam)
 Xanax (Alprazolam)Xanax (Alprazolam)
 Ativan (Lorazepam)Ativan (Lorazepam)
 Valium (Diazepam)Valium (Diazepam)
 Be aware of potential for addiction**Be aware of potential for addiction**

Mental Health, Incarceration, andMental Health, Incarceration, and
ProbationProbation
 Probation is the most common form of sentencingmost common form of sentencing in the United
States, with more than halfmore than half of the correctional population supervised in
the community (Skeem et al., 2017).
 In the US, rates of mental illnesses are 3 to 6 times higher3 to 6 times higher in the
criminal justice population than the general population (Skeem et al., 2017).
 Each year, approximately 2 million people2 million people with serious mental illness are
booked into the nation’s jails (Skeem et al., 2017).
 Individuals with mental illness generally spend a longer duration in custody,
and upon release, they are more likely to be reincarceratedmore likely to be reincarcerated (Skeem et
al., 2017).
 Surveillance-style probation is being replaced with balanced supervision
approaches that include evidence-based practices shown to reduce
recidivism (Skeem et al., 2017).

Identifying IndividualsIdentifying Individuals
Appropriate for SpecialtyAppropriate for Specialty
CaseloadCaseload
 Pretrial Services Report and/or Presentence Investigation ReportPretrial Services Report and/or Presentence Investigation Report
 Consider criminal historyConsider criminal history
 History of violence / multiple arrestsHistory of violence / multiple arrests
 Consider psychosocial historyConsider psychosocial history
 Past treatment for mental health or dual diagnosisPast treatment for mental health or dual diagnosis
 History of suicide attempts, hospitalizations, psychotropic medication(s)History of suicide attempts, hospitalizations, psychotropic medication(s)
 DOC and/or Halfway House RecordsDOC and/or Halfway House Records
 History of disciplinary action in DOC suggesting volatilityHistory of disciplinary action in DOC suggesting volatility
 Review Psychiatric Evaluations and/or medications prescribed in custodyReview Psychiatric Evaluations and/or medications prescribed in custody
 Statement of Charges for instant offense or prior offensesStatement of Charges for instant offense or prior offenses
 Consider if mental illness may have played a roleConsider if mental illness may have played a role
 Presence of bizarre or odd behaviors / comments?Presence of bizarre or odd behaviors / comments?
 Information gleamed from intake and internal assessmentsInformation gleamed from intake and internal assessments
 Inquire if there is a history of mental health concerns and rely on your own observationsInquire if there is a history of mental health concerns and rely on your own observations
 Seek input from collateral sources, if possibleSeek input from collateral sources, if possible
 Refer for Mental Health / Psychiatric Assessment, if appropriateRefer for Mental Health / Psychiatric Assessment, if appropriate
 Request modification of supervision conditions to include mental health treatment, if appropriateRequest modification of supervision conditions to include mental health treatment, if appropriate
Review case-specific documentation includingReview case-specific documentation including ::

Identifying Individuals appropriateIdentifying Individuals appropriate
for Specialist caseloadfor Specialist caseload
 Consider current mental health statusConsider current mental health status
 Does the individual have insight into their mental health concerns?Does the individual have insight into their mental health concerns?
 Does he/she display a willingness to participate in treatment?Does he/she display a willingness to participate in treatment?
 Is the individual actively symptomatic? Are symptoms controlled / manageable or doIs the individual actively symptomatic? Are symptoms controlled / manageable or do
symptoms significantly interfere with daily life?symptoms significantly interfere with daily life?
 Identify Risk LevelIdentify Risk Level
 If case assesses asIf case assesses as highhigh intensity, and the individual has a history of chronic mentalintensity, and the individual has a history of chronic mental
illness, specialist supervision may be appropriateillness, specialist supervision may be appropriate
 If case assesses as moderate, but the individual isIf case assesses as moderate, but the individual is actively symptomaticactively symptomatic, specialist, specialist
supervision may be appropriatesupervision may be appropriate
 Management staff or specialists may consider developing aManagement staff or specialists may consider developing a
checklist or screening tool to determine when a case should bechecklist or screening tool to determine when a case should be
placed on a specialist caseloadplaced on a specialist caseload
 High Risk…High Risk…
 History of psychosis, significant mental illness, or suicide attemptsHistory of psychosis, significant mental illness, or suicide attempts
 Medication non-compliant…Medication non-compliant…
 History of violence…History of violence…

Specialty Supervision vs.Specialty Supervision vs.
Traditional SupervisionTraditional Supervision
 Key Characteristics ofKey Characteristics of Specialty Mental Health SupervisionSpecialty Mental Health Supervision::
 Reduced caseload sizesReduced caseload sizes
 20 or less for intensive supervision (American Probation and Parole Association)20 or less for intensive supervision (American Probation and Parole Association)
 50 or less for moderate to high risk (American Probation and Parole Association)50 or less for moderate to high risk (American Probation and Parole Association)
 **Reference:**Reference: https://www.appa-net.org/eweb/docs/APPA/stances/ip_CSPP.pdfhttps://www.appa-net.org/eweb/docs/APPA/stances/ip_CSPP.pdf
 Increased contact standardsIncreased contact standards
 Balance of office, home, and community-based visitsBalance of office, home, and community-based visits
 Specific and ongoing training in mental healthSpecific and ongoing training in mental health
 In-service or formal education in mental health, psychology, and/or social workIn-service or formal education in mental health, psychology, and/or social work
 Focus on rapid treatment referrals and establishing relationships withFocus on rapid treatment referrals and establishing relationships with
treatment providerstreatment providers
 A specialty officer should be an in-house expert on treatment resources in the supervisionA specialty officer should be an in-house expert on treatment resources in the supervision
areaarea
 An understanding of the barriers associated with mental illnessAn understanding of the barriers associated with mental illness
 Specialty officers must have the ability to manage interpersonal conflicts, professionally, andSpecialty officers must have the ability to manage interpersonal conflicts, professionally, and
develop rapport with clients (Fair but firm)develop rapport with clients (Fair but firm)
 Specialty officers must appropriately balance “control” (law enforcement) with “care” (socialSpecialty officers must appropriately balance “control” (law enforcement) with “care” (social
work)work)

Are Specialty CaseloadsAre Specialty Caseloads
Effective?Effective?
 ResearchResearch: Comparing Public Safety Outcomes for Traditional Probation vs.: Comparing Public Safety Outcomes for Traditional Probation vs.
Specialty Mental Health ProbationSpecialty Mental Health Probation
Jennifer L. Skeem, PhD; Sarah Manchak, PhD; Lina Montoya, MA (2017)Jennifer L. Skeem, PhD; Sarah Manchak, PhD; Lina Montoya, MA (2017)
 The Study:
 Researchers recruited 359 probationers with mental illnesses in Texas and
California.
 About half of the offenders were put on specialty probation while the other
half were on traditional caseloads.
 Probationers and their officers were interviewed to determine progress
 Researchers used FBI arrest records to assess which probationers re-
offended
 All participants were followed for at least two years
 Conclusions:
 52% of individuals on traditional caseloads were re-arrested within a 2-year
period, as compared to onlyonly 29% of individuals placed on mental29% of individuals placed on mental
health specialty caseloadshealth specialty caseloads.
 The benefits of specialty probation lasted for up to five years
Findings are published in the Journal of the American Medical Association — Psychiatry. See:
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2647078

Research on SpecialtyResearch on Specialty
Caseloads (Cont.)Caseloads (Cont.)
 ResearchResearch: High-fidelity specialty mental health probation improves officer: High-fidelity specialty mental health probation improves officer
practices, treatment access, and rule compliance.practices, treatment access, and rule compliance.
Manchak SM, Skeem JL, Kennealy PJ, Louden JE. (2014)Manchak SM, Skeem JL, Kennealy PJ, Louden JE. (2014)
 The Study:
 Researchers tested whether individuals on a specialty caseload differed from a
those on a traditional caseload in the following areas:
 Officers' practices,
 Probationers' treatment access, and
 Probationers' rule violations.
 Conclusions: Specialty Caseloads resulted in…
 Better officer practices (e.g., problem-solving rather than sanction threats;
higher quality relationships with probationers);
 Researchers concluded that officers' use of sanctions and threats
increasedincreased probationers' risk of incurring a probation violation, whereas
high-quality officer-probationer relationships protected against this
outcome.
 Greater rates of treatment involvement, and
 Lower rates of re-arrests and violation reportsSee: https://www.ncbi.nlm.nih.gov/pubmed/24749700

Research on Evidence-BasedResearch on Evidence-Based
Supervision StrategiesSupervision Strategies
 ResearchResearch:: Preventing Criminal Recidivism Through Mental Health
and Criminal Justice Collaboration
J. Steven Lamberti (2016)
 Key Points:
 Mental health–criminal justice collaboration is essential in managing
justice-involved individuals with serious mental illness in community
settings
 It is important to combine best practices in treating mental illnesscombine best practices in treating mental illness and
co-occurring addiction with correctional best practiceswith correctional best practices aimed at
preventing criminal recidivism
 Effective Interventions:
 Target risk factors known to drive criminal behavior
 Are action-oriented and require individuals to demonstrate appropriate behaviors
 Use interventions that reinforce appropriate behaviors while extinguishing
inappropriate behaviors

Traditional SupervisionTraditional Supervision Mental Health SupervisionMental Health Supervision
Task: Engaging the individual at the commencement of supervision
• Reviewing conditions of supervision and clarifying expectations • Identifying available treatment services and initiate rapid referrals
• Ensuring healthcare coverage to obtain treatment
Task: Assessing the individual to address risks and needs
• Completing a risks / needs assessment • Completing a mental health, psychiatric, and/or psychosocial
assessment
Task: Case Planning and monitoring of conditions
• Focus on adherence to court order, realistic goals, and completion
of sentence
• Establishing treatment-specific resources and supports
• Focus on mental health stability as foundation for other goals
Task: Monitoring and supervising the offender
• Encouraging personal responsibility in completing conditions
• Focusing on risks and needs
• Ensuring compliance with conditions
• Strong collaboration with treatment provider / collateral sources
• Monitoring for decompensation
• Frequent contacts and more support may be necessary
• Reminders and encouragement about treatment and medication
compliance / Psychoeducation
Task: Problem Solving and addressing non-compliance
• Use controlling and correctional strategies to encourage compliance
• Reinforcing conditions of supervision and expectations
• Reporting violations to court
• Holding offender accountable
• Consider barriers to compliance associated with mental health
• Consider therapeutic options to respond to non-compliance
• Discuss alternatives to punishment with treatment provider
Task: Transitioning off supervision at sentence completion
• Reinforcing accomplishments while on supervision and encouraging
law-abiding behavior after sentence completion
• Education on local mental health resources
• Discuss benefits of ongoing engagement in treatment
• Involvement of treatment provider and collateral contacts when
planning for expiration
Reference: Preventing Criminal Recidivism Through Mental Health and Criminal Justice Collaboration
J. Steven Lamberti (2016)

FocusingFocusing onlyonly on Mental Healthon Mental Health
is insufficientis insufficient
 The Risk, Need, and Responsivity principleThe Risk, Need, and Responsivity principle::
 RiskRisk
 Properly assess risk and match intensity of services to risk levelProperly assess risk and match intensity of services to risk level
 Consider risk level when implementing controlling and correctional strategiesConsider risk level when implementing controlling and correctional strategies
 NeedsNeeds
 Targeting criminogenic needs reduces recidivismTargeting criminogenic needs reduces recidivism in all populationsin all populations
 Antisocial Attitudes / ValuesAntisocial Attitudes / Values
 Cognitive Behavioral Therapy (CBT) is effectiveCognitive Behavioral Therapy (CBT) is effective
 Moral Reconation Therapy (MRT)Moral Reconation Therapy (MRT)
 Thinking for a ChangeThinking for a Change
 Anti-social peersAnti-social peers
 Substance Abuse,Substance Abuse,
 Unemployment,Unemployment,
 Lack of problem-solving skills / self-controlLack of problem-solving skills / self-control
 ResponsivityResponsivity
 Not all offenders are the sameNot all offenders are the same
 Consider each individual’s mental health barriers, level of motivation,Consider each individual’s mental health barriers, level of motivation,
history of abuse or neglect, access to resources etc.history of abuse or neglect, access to resources etc.

ResearchResearch:: Envisioning the Next Generation of Behavioral
Health and Criminal Justice Interventions
Matthew W. Epperson, Nancy Wolff, Robert D. Morgan, William H. Fisher, B. Christopher Frueh, and Jessica Huening (2014)
 Researchers distinguish between “first generation” and “secondResearchers distinguish between “first generation” and “second
generation” intervention strategies:generation” intervention strategies:
 First Generation StrategiesFirst Generation Strategies::
 The principal objective is to create or strengthen linkages tocreate or strengthen linkages to
effective mental health services.effective mental health services.
 Researchers ArgueResearchers Argue::
 People with mental illness have encounters with the criminal
justice system for many of the same reasons as people withoutfor many of the same reasons as people without
mental health concernsmental health concerns
 Effective mental health treatment is an important response to
the unique needs of this population, but focusing on treatment
as the primary / sole intervention is insufficient to make a
meaningful impact on recidivism.
See: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4142111/

Research: Envisioning the Next Generation of Behavioral Health andResearch: Envisioning the Next Generation of Behavioral Health and
Criminal Justice InterventionsCriminal Justice Interventions
 For most persons with significant mental illness (SMI) criminal involvement is not simply
explained by a lack of mental health treatment; but rather, by a complex interplay of
individual and environmental factors resulting in significant stress.
 Person-Place Framework
 Person-Level (Individual) FactorsPerson-Level (Individual) Factors::
 Mental health diagnosis, criminogenic needs, and trauma exposureMental health diagnosis, criminogenic needs, and trauma exposure
 Place (environment) FactorsPlace (environment) Factors::
 Individuals with SMI often live in environments that increase their risks ofIndividuals with SMI often live in environments that increase their risks of
criminal justice involvement, including forms of social and environmentalcriminal justice involvement, including forms of social and environmental
disadvantage.disadvantage.
 Exposure to crime / violence, lack of community resources, easyExposure to crime / violence, lack of community resources, easy
access to drugs and alcohol, antisocial peer influencesaccess to drugs and alcohol, antisocial peer influences
 StressStress::
 Defined asDefined as: The interaction of person and place risk factors: The interaction of person and place risk factors
 Stress increases the likelihood of behaviors that are harmful to individualsStress increases the likelihood of behaviors that are harmful to individuals
and the community and produces pressure toward criminal justiceand the community and produces pressure toward criminal justice
entanglemententanglement

As found in: Envisioning the Next Generation of Behavioral Health and Criminal Justice Interventions

Risk Factors Interventions
Medication Adherence • Build an understanding of how medications regulate and
improve the body's functioning
• Educate on the biological mechanisms of mental illness and
the importance of treating these disorders pharmacologically
• Review benefits and side effects of various types of
medications.
• Empower clients to engage clinicians in open dialogue on
topics relating to medications, specifically side effects
encountered.
Criminogenic Risks • Help clients understand the link between thoughts, values,
and behaviors.
• Promote social skills development and problem-solving skills
• Discuss health ways to respond to anger and frustration
• Challenge criminal thinking patterns and association with
criminal associates.
• Encourage psychiatric stabilization and self-care
• Build environmental supports for prosocial living, support
healthy interpersonal relationships, and increase
participation in prosocial activities such as employment,
education achievement, volunteering, and recreational
activities.
• Consider CBT-based interventions to challenge antisocial
thinkingAddiction(s) Risks • Assess type and severity of addiction
• Examine antecedents to addictive behavior and identify
circumstances that trigger addictive behavior.
• Discuss relapse-prevention strategies
• Examine the client's life goals and reinforce how reducing
addictive behavior can assist the client in reaching them.
• Encourage healthy coping skills
Adapted from: Envisioning the Next Generation of Behavioral Health and Criminal Justice Interventions

Risk Factors Interventions
Trauma Risks • Incorporate a “trauma-informed” care approach
• Increasing awareness of trauma exposure, its
consequences, and how best to engage clients who have
experienced trauma.
• Identify, acknowledge, and provide support for clients with a
history of traumatic experiences
• Respond to clients in ways that are respectful, reassuring,
and hopeful about the possibility of recovery.
• Engage client’s treatment provider and guide the individual
through a process of understanding the connection between
trauma and related responses (e.g., depression, anxiety,
addictions, criminal behavior)
Stress Risks • Build skills for managing stress in healthy ways.
• Discuss how stress can impact health, decision-making, and
compliance with supervision
• Incorporate mindfulness-based techniques to promote self
control and reduce feelings of stress
• Identify triggers and reinforce pro-social responses to stress
Social and Environmental Risks • Assessess needs related to social and environmental
disadvantage including housing, education, and job training
• Develop resources and provide linkages to necessary
services to mitigate social and environmental risks
• Discuss how to the client can identify and avoid high risk
environments / situations. If avoidance is not possible,
discuss how the individual may respond pro-socially to high
risk environments
• Help client distinguish between “good friends” and
individuals who are interested in causing harm or
encouraging criminal activityAdapted from: Envisioning the Next Generation of Behavioral Health and Criminal Justice Interventions

Case Planning for EffectiveCase Planning for Effective
SupervisionSupervision
 Gather as much information as possible about the individual’s past andGather as much information as possible about the individual’s past and
present circumstancespresent circumstances
 Prior mental health diagnoses? Is the individual actively symptomatic? History of substance abusePrior mental health diagnoses? Is the individual actively symptomatic? History of substance abuse
or violence? Currently on medication? Is an updated assessment needed? Is health insuranceor violence? Currently on medication? Is an updated assessment needed? Is health insurance
needed to connect with services? Stable housing? Entitlements? Family or community support?needed to connect with services? Stable housing? Entitlements? Family or community support?
 Obtain information from collateral contacts (i.e. family, trusted friends,Obtain information from collateral contacts (i.e. family, trusted friends,
religious leaders)religious leaders)
 Collaterals can be highly beneficial for individuals resistant to talk about mental health concernsCollaterals can be highly beneficial for individuals resistant to talk about mental health concerns
 Collaterals are helpful when an individual is decompensatingCollaterals are helpful when an individual is decompensating
 Complete risk/needs/responsivity assessmentComplete risk/needs/responsivity assessment
 The risk level should drive the intensity of supervision and interventionsThe risk level should drive the intensity of supervision and interventions
 Individuals who are high risk, diagnosed with a chronic mental health disorder, and activelyIndividuals who are high risk, diagnosed with a chronic mental health disorder, and actively
symptomatic should be considered for placement on specialized caseloads.symptomatic should be considered for placement on specialized caseloads.
 Criminogenic needs should be targeted in addition to focusing on mental health concernsCriminogenic needs should be targeted in addition to focusing on mental health concerns
 Responsivity factors, such as mental illness, should be identified and the plan should beResponsivity factors, such as mental illness, should be identified and the plan should be
individualized based on specific risk, need, and responsivity factorsindividualized based on specific risk, need, and responsivity factors
 Initiate appropriate referrals to federal, state, and local agencies to addressInitiate appropriate referrals to federal, state, and local agencies to address
risks and needsrisks and needs
 If funding is available, consider paying for treatment for the highest risk offendersIf funding is available, consider paying for treatment for the highest risk offenders
 If the Agency is unable to pay for treatment, individuals will likely need to obtain health insurance asIf the Agency is unable to pay for treatment, individuals will likely need to obtain health insurance as
quickly as possible. Consider developing liaisons with Department of Social Services, Department ofquickly as possible. Consider developing liaisons with Department of Social Services, Department of
Health and Mental Hygiene, Behavioral Health Administration, and SAMHSAHealth and Mental Hygiene, Behavioral Health Administration, and SAMHSA
 It is imperative to establish partnerships with local mental health providers to facilitate swift referralsIt is imperative to establish partnerships with local mental health providers to facilitate swift referrals
for treatment. Delays could lead to rapid decompensation and recidivismfor treatment. Delays could lead to rapid decompensation and recidivism

Case PlanningCase Planning
 Prioritize case plan objectives, consider barriers, and establish realisticPrioritize case plan objectives, consider barriers, and establish realistic
goalsgoals
 Basic needs need to be addressed before higher-level goals (i.e. food, shelter, clothing)Basic needs need to be addressed before higher-level goals (i.e. food, shelter, clothing)
 Barriers such as transportation, medical or physical ailments, and low cognitive functioning need toBarriers such as transportation, medical or physical ailments, and low cognitive functioning need to
be consideredbe considered
 Focus on mental stability as a foundation, but target broader criminogenic needs to reduceFocus on mental stability as a foundation, but target broader criminogenic needs to reduce
recidivismrecidivism
 Be clear about responsibilities, but expect some “technical” non-compliance.Be clear about responsibilities, but expect some “technical” non-compliance.
Respond with graduated sanctionsRespond with graduated sanctions
 Expectations should be made clear, but individuals with significant disorders may need multipleExpectations should be made clear, but individuals with significant disorders may need multiple
reminders or written remindersreminders or written reminders
 Missed office appointments or treatment sessions are likely to occur – Individuals should be heldMissed office appointments or treatment sessions are likely to occur – Individuals should be held
accountable, but the response should be proportional to the violationaccountable, but the response should be proportional to the violation
 Consider underlying mental health concerns and employ graduated sanctions (i.e. verbalConsider underlying mental health concerns and employ graduated sanctions (i.e. verbal
admonishment, written warning, supervisory meeting, etc.)admonishment, written warning, supervisory meeting, etc.)
 Continually develop rapport with the offender and maintain regular contactContinually develop rapport with the offender and maintain regular contact
with treatment providers and collateral contactswith treatment providers and collateral contacts
 The relationship with the offender is the best predictor of successThe relationship with the offender is the best predictor of success
 Treatment providers are critically important to the offender’s successful adjustment – 3-way staffingTreatment providers are critically important to the offender’s successful adjustment – 3-way staffing
should occur with the offender and treatment providershould occur with the offender and treatment provider
 If possible, seek periodic updates from collateral sources concerning the individual’s progressIf possible, seek periodic updates from collateral sources concerning the individual’s progress
 Re-evaluate the plan at fixed intervals (6-12 months), review progress withRe-evaluate the plan at fixed intervals (6-12 months), review progress with
objectives, and adjust the plan to reflect successes or set-backsobjectives, and adjust the plan to reflect successes or set-backs
 Consider barriers for any objective that are incomplete and problem-solveConsider barriers for any objective that are incomplete and problem-solve
 Continue to evaluate risk of danger to self and the community, consider a downgrade fromContinue to evaluate risk of danger to self and the community, consider a downgrade from
specialist/intensive supervision if the individual demonstrates compliance and stability for a fixedspecialist/intensive supervision if the individual demonstrates compliance and stability for a fixed
time-frametime-frame

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