< Previous40 PERSPECTIVES VOLUME 44, NUMBER 2 ADAPTING A CLINICAL CASE CONSULTATION MODEL TO ENHANCE CAPACITY OF SPECIALTY MENTAL HEALTH PROBATION OFFICERS BY MARILYN GHEZZI, TONYA B. VAN DEINSE, ERIKA L. CRABLE, KAREN BUCK, MAGGIE BREWER, SONYA BROWN, NICOLE SULLIVAN, AND GARY S. CUDDEBACK41 AMERICAN PROBATION AND PAROLE ASSOCIATION Specialty mental health probation (SMHP) is a form of modified supervision designed to enhance mental health treatment engagement and reduce probation violations and recidivism among adults with mental illnesses (Manchak, Skeem, Kennealy, & Eno Louden, 2014; Skeem, Manchak, & Montoya, 2017; Wolff et al., 2014). Typical SMHP models have five core elements: (1) reduced caseload size; (2) ongoing mental health training; (3) designated and exclusive caseloads of individuals with mental illnesses; (4) coordination with internal and external resources; and (5) use of a problem-solving supervision orientation (Manchak et al., 2014; Skeem, Emke-Francis, & Eno Louden, 2006; Skeem et al., 2017; Wolff et al., 2014). Given the complexity of supervision duties in this setting, strategies are needed to enhance SMHP officers’ capacity for acquiring new knowledge and practicing a mental health-focused skill set. Clinical case consultation has been identified as an effective implementation strategy that utilizes practice feedback, coaching, and active learning to support the uptake of evidence-based practices (EBPs) in mental health services settings (Nadeem, Gleacher, & Beidas, 2013). Research has shown the effectiveness of clinical case consultation in mental health services (Beidas, Edmunds, Marcus, & Kendall, 2012; Fritz et al., 2013; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Sholomskas et al., 2005), but studies to date have not specifically examined clinical case consultation in regard to SMHP. Our research team conducted a study with the North Carolina Department of Public Safety that examined the effectiveness of a clinical case consultation model we designed to provide education and skills training to SMHP officers. The introduction of clinical case consultation in this setting was intended to enhance the SMHP officers’ ability to problem solve cases, provide more effective supervision of individuals with mental illnesses, balance criminal justice and mental health considerations in making supervision decisions, and interface with local behavioral health and social service providers. In this article, we describe our study and its outcomes. To aid in further understanding of this subject, we cover the core features of clinical case consultation for SMHP officers, present some lessons learned, and offer suggestions for probation agencies considering using clinical case consultation to build and enhance SMHP programs. PROCESS FOR PROVIDING CLINICAL CASE CONSULTATION Clinical case consultation was delivered by a licensed clinical social worker (LCSW) with over 20 years of community mental health experience in working with individuals 42 PERSPECTIVES VOLUME 44, NUMBER 2 who have severe and persistent mental illnesses. This LCSW provided clinical case consultation via monthly meetings with SMHP officers and their specialty mental health chief probation officers (the mid- level managers who directly supervise the state’s probation officers). Most consultation meetings occurred in person, with the consultant traveling to meet with the SMHP officers and chiefs in their probation offices, although meetings were occasionally conducted over the phone. Prior to these in-person and phone consultations, officers were asked to identify cases to present and discuss using a case presentation format (i.e., presentation of diagnosis and/ or symptoms, brief psychosocial history, and current behaviors and problems). Since the officers were not familiar with this case presentation format, which is routinely used in mental health settings, an orientation to its use was provided verbally and in writing (see Table 1). The LCSW consultant, SMHP officers, and chiefs discussed each case, and the LCSW offered insights regarding mental health symptoms and behaviors and their implications for treatment and potential impact on an individual’s ability to meet probation requirements. This process is described in more detail below. COMPONENTS OF CLINICAL CASE CONSULTATION ADAPTED FOR SMHP Typical clinical case consultation models promote knowledge and skills acquisition via the following seven core elements, as defined by Nadeem et al. (2013): (1) continued training; (2) problem-solving to address implementation barriers; (3) provider engagement; (4) direct case application; (5) appropriate treatment adaptation; (6) accountability; (7) mastery skill-building; and (8) planning for sustainability. Although these core elements have been primarily used in mental health services to enhance the uptake of evidence-based practices (Beidas et al., 2012; Edmunds, Beidas, & Kendall, 2013; Nadeem et al., 2013), they have broad applicability for implementing evidence-informed correctional practices, such as SMHP. CONTINUED TRAINING Mental health training was provided to SMHP officers via face-to-face biannual training sessions and a six-part web-based training. For the biannual component, all SMHP officers and their respective chiefs (i.e., direct supervisors) participated in 12 hours of training offered over a two-day period. Topics included: (1) as- needed booster sessions on mental health signs and symptoms; (2) introductory and refresher sessions on how SMHP officers and chiefs can best utilize case consultation (e.g., case formulation and 43 AMERICAN PROBATION AND PAROLE ASSOCIATION reporting); (3) introductory and booster sessions for dual disorder motivational interviewing adapted specifically for SMHP; and (4) updates regarding any topics pertaining to policy or protocol (e.g., effective notetaking and documentation). With regard to initial and on-going training, all SMHP officers were required to view the following six mental health training modules delivered through the state’s learning management system: (1) how to interpret and discuss individuals’ responses to the state’s offender mental health screen; (2) severe and persistent mental illnesses and symptoms; (3) psychiatric medications, uses and side effects; (4) personality disorders, traumatic brain injury, and other disorders; (5) mental health services for individuals with severe and persistent mental illnesses; and (6) self-care for probation officers. Content covered in the biannual training and the six learning modules was then reinforced during monthly case consultation sessions with the LCSW consultant, which allowed SMHP officers to ask specific questions about applying different skills and interventions with the individuals on their caseloads. During case consultation, the LCSW consultant was also able to identify additional training needs and resources. For example, officers identified that working with homeless individuals was particularly challenging. In response, our team arranged for regular contact with a local housing expert from the area’s mental health managed care organization. In another instance, SMHP officers indicated that although they had experience supervising perpetrators of intimate partner violence (IPV), they were much less clear about how to talk with survivors of IPV and did not know about local IPV services and resources. This led to the development and delivery of a brief segment about IPV during subsequent biannual training. PROBLEM SOLVING IMPLEMENTATION BARRIERS Monthly case consultations allowed officers to discuss challenges that arose in implementing SMHP, particularly during the early phases of implementation. Officers noted challenges related to: (1) working with specific individuals on their caseloads (e.g., those with particularly challenging mental health symptoms); (2) difficulties maintaining the reduced caseload size of 40-50 individuals, often due to officer turnover involving regular probation officers which created vacancies in the department; feeling overwhelmed with their workload; (3) juggling competing demands; (4) managing barriers in communication about the intervention during early implementation; and, (5) difficulties connecting individuals with services due to limited local mental health services. 44 PERSPECTIVES VOLUME 44, NUMBER 2 The SMHP officers raised supervision concerns during clinical case consultations and worked with the LCSW consultant to solve problems involving a variety of issues. Problem-solving approaches often involved the identification of potentially relevant interventions and additional resources available to address officers’ specific needs or the needs of individuals on their caseloads. PROVIDER ENGAGEMENT Nadeem, Gleacher, and Beidas (2013) describe the importance of engaging providers and other key organizational stakeholders, including leadership and supervisors, to achieve successful implementation of an intervention. During the early phases of implementing case consultation, for example, the LCSW consultant would regularly check in with the SMHP officers’ chiefs about the status of the SMHP intervention in order to address questions or challenges raised by the officers and chiefs. The LCSW consultant, chiefs, and SMHP officers all believed that this additional communication with the LCSW consultant was beneficial and decided to formalize the process by inviting the chiefs to each consultation session. Expanding consultation sessions to include the chief officer rather than just the SMHP officer and LCSW consultant improved the quality of the case consultation meetings because the chief officers were able to share their criminal justice and administrative expertise and provide additional guidance for managing each supervision case. Including the chief officer in these consultations had the added benefit of actively engaging the chiefs in the delivery of SMHP. Furthermore, the LCSW consultant met regularly with state-level Department of Public Safety community corrections’ administrators to provide feedback on implementation, troubleshoot barriers (e.g., prohibitively large SMHP officer caseload sizes), and identify additional training needs and resources for the SMHP officers and chiefs. DIRECT CASE APPLICATION Monthly consultation sessions were primarily used to discuss cases that SMHP officers found difficult, confusing, or frustrating. Cases were viewed as challenging for various reasons, including: (1) specific characteristics of individuals on the caseload (e.g., lack of motivation, confusing speech patterns, cognitive deficits); (2) problems identifying and accessing resources (e.g., transportation, mental health providers, housing); (3) officers’ self-identified limitations for specific skill sets (e.g., lack of experience with motivational interviewing or lack of understanding mental health services); and (4) officers’ emotional reactions to individuals on their caseloads. In order to facilitate the consultation process to maximize time spent identifying resources 45 AMERICAN PROBATION AND PAROLE ASSOCIATION and practicing skills, the LCSW consultant developed a protocol for case consultation that asked each officer to prepare for the clinical consultation meeting by bringing the case file and developing the case description using a structured format (see Table 1). TABLE 1: CASE REPORT FORMAT Case Report TaskDescription Orientation to the case Provide a brief demographic description that includes age, race, gender, criminal charge, and other pertinent background information (e.g., “Probationer is a 24-year old white female who is on probation for marijuana possession with intent to distribute”). Summary of life domains Provide a brief description of the individual’s status across multiple life domains (e.g., basic needs, medical problems, mental health, substance use, housing, etc.). Examples may include the following: •How long has the individual been on probation? •What is the individual’s living situation? Who lives or stays in the home? •Does the individual have a partner or children? •Is the individual working or on disability? •What do you know about the individual’s mental health diag- nosis or mental health problems? •What do you know about the individual’s substance use? •Does the individual have any current or past mental health or substance use treatment? Topic for consultation After an overview of the individual is provided, SMHP officers should indicate what question or challenge that they would like to discuss with the consultant. Through this process, officers become increasingly aware of the importance of an individual’s history and social context. The LCSW consultant would then provide more information about the identified issue (such as explaining why an actively psychotic individual might be suspicious about taking medication), reinforce officer skills (e.g., motivational interviewing), problem solve system-level challenges (e.g., securing transportation to provider appointments in a rural area), and/or provide emotional support and validation to the SMHP officers, which often served to boost morale and reduce burnout. 46 PERSPECTIVES VOLUME 44, NUMBER 2 APPROPRIATE TREATMENT ADAPTATION The goal of delivering clinical case consultation was to promote consistency between real-world implementation of SMHP and the prototypical model of SMHP. However, SMHP model components can and should be adapted to the local contexts to further aid implementation and promote sustainability. For example, the core components of SMHP specify that officers develop relationships and engage regularly with community-based mental health and social service providers. As such, officers delivering SMHP may need to tailor their approach to building and maintaining these relationships based on the capacity of the local service system. Officers participating in clinical case consultations described how coordination with external resources varied widely from county to county based on the number of mental health providers and the level of involvement and support from the local managed care organization (the entity responsible for managing the array of behavioral health services for a given catchment area). Counties that had well- established partnerships between criminal justice entities and the mental health system required less consultation around service coordination or information about the types of services available; rather, these SMHP officers sought assistance in addressing specific communication challenges between officers and mental health service providers (e.g., responses to requests for treatment confirmation) or ways to advocate for higher levels of services for individuals on their caseloads. ACCOUNTABILITY The clinical case consultation process involved a monthly commitment between the LCSW consultant, SMHP officers, and their chiefs. For officers, this commitment required prioritizing consultation time while balancing typical workload responsibilities, reflecting on current caseload challenges to select cases for discussion, preparing materials for the case report, and actively engaging in the consultation session. In addition, state- level administrators endorsed clinical case consultation and asked that SMHP officers and chiefs participate regularly, thereby increasing accountability. In turn, the primary way in which the LCSW consultant demonstrated her accountability was the consistent application of her skillset to address officers’ and chief’s challenges. In particular, the LCSW consultant demonstrated clinical knowledge, “fluency” in probation terms and acronyms, knowledge of probation’s primary mission of public safety, rapport building with officers and chiefs, and knowledge about the local mental health system’s types of services and referral process. In addition, the LCSW consultant 47 AMERICAN PROBATION AND PAROLE ASSOCIATION demonstrated accountability and commitment through her regular presence at the probation offices, which were often several hours away from the university, and by making herself available to the SMHP officers and chiefs as challenges arose. MASTERY SKILL BUILDING Although most of the consultation sessions were structured around the case report and feedback process, a portion of sessions were used for role plays and modeling behaviors in order to reinforce officers’ skills to address specific case-related challenges. For example, an officer may need ideas about how to talk with a person who is hearing voices. The LCSW consultant can use the consultation session to model this behavior for the officer by providing language that will be non-threatening as well as ways to sidestep delusional content in a conversation with the individual. In addition, the LCSW consultant regularly worked with officers to discuss how motivational interviewing could be integrated into SMHP officers’ supervision sessions. The LCSW consultant also encouraged SMHP officers to audiotape role plays of motivational interviewing with a fellow officer and submit them to the LCSW consultant for review. PLANNING FOR SUSTAINABILITY The final element in the case consultation model (Nadeem et al., 2013) is planning for sustainability. Although the most critical time to implement a clinical case consultation strategy for SMHP may be during initial and early implementation, SMHP officers and their chiefs reported that they benefitted from ongoing consultation. The need for ongoing clinical case consultation is expected because probation officers are using an interdisciplinary approach that requires them to apply knowledge about mental health conditions and anticipate potential supervision challenges for individuals with mental illnesses who are on probation. Although the benefits of ongoing clinical case consultation may be evident, it is a resource-intensive model that requires a plan for sustainability. Officers and their direct supervisors must dedicate time to preparing for and participating in consultation meetings. Additionally, probation departments will need to consider the cost of funding such as model. For smaller pilot projects, it is possible that one LCSW consultant is sufficient. However, depending on the scale of a state or jurisdiction’s approach, multiple consultant positions will be needed. An untested, but potentially cost-efficient model for states, larger county- or regional-level jurisdictions may 48 PERSPECTIVES VOLUME 44, NUMBER 2 include employing a social work assistant to conduct clinical case consultations with officers and chiefs. The clinical case consultation model described here evolved over the last several years and has focused on building the capacity of senior officers and chiefs who may later serve as coaches. Building the capacity and expertise of others within the agency can decrease reliance on an external case consultant and enhance model sustainability. Jurisdictions with multiple levels of management (e.g., direct supervisors, mid-level managers) may have an infrastructure in place that would be conducive to this type of coaching model. FUTURE RESEARCH In this article, we describe a model of clinical case consultation adapted for probation settings as an implementation strategy for SMHP. Case consultation has the potential to be an effective strategy for implementing evidence- informed interventions within criminal justice settings, but additional research is needed. Agencies and their research partners interested in this consultation model for SMHP should consider piloting such a strategy in a small number of counties or jurisdictions to examine the feasibility of the model. In addition, agency administrators and researchers should consider examining the outcomes of clinical case consultation regarding SMHP officer knowledge and skills. REFERENCES Beidas, R. S., Edmunds, J. M., Marcus, S. C., & Kendall, P. C. (2012). 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A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72(6), 1050. Nadeem, E., Gleacher, A., & Beidas, R. S. (2013). Consultation as an implementation strategy for evidence-based practices across multiple contexts: Unpacking the black box. Administration and Policy in Mental Health and Mental Health Services Research, 40(6), 439-450. Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don’t train in vain: A dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology, 73(1), 106.49 AMERICAN PROBATION AND PAROLE ASSOCIATION Skeem, J. L., Emke-Francis, P., & Eno Louden, J. (2006). Probation, mental health, and mandated treatment a national survey. Criminal Justice and Behavior, 33(2), 158-184. doi: 10.1177/0093854805284420 Skeem, J. L., Manchak, S., & Montoya, L. (2017). Comparing public safety outcomes for traditional probation vs specialty mental health probation. JAMA Psychiatry, 74(9), 942-948. doi:10.1001/ jamapsychiatry.2017.1384 Wolff, N., Epperson, M., Shi, J., Huening, J., Schumann, B. E., & Sullivan, I. R. (2014). Mental health specialized probation caseloads: Are they effective? International Journal of Law and Psychiatry, 37, 464–472. doi: 10.1016/j.ijlp.2014.02.019 ABOUT THE AUTHORS MARILYN GHEZZI is a clinical associate professor at the University of North Carolina at Chapel Hill School of Social Work and is the corresponding author on this manuscript. Email: edu; phone: (919) 962-6490. TONYA B. VAN DEINSE is a clinical associate professor at the University of North Carolina at Chapel Hill School of Social Work. ERIKA L. CRABLE is a research fellow at the Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA and PhD candidate in the Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA. KAREN BUCK is the Evidence-based Practice Administrator, North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, Raleigh, NC. MAGGIE BREWER is Deputy Director, North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, Raleigh, NC. SONYA BROWN is the Social Work Practice Administrator, North Carolina Department of Public Safety, Division of Adult Correction and Juvenile Justice, Raleigh, NC. NICOLE SULLIVAN is the Director of Reentry Programs and Services, North Carolina Department of Public Safety, Raleigh, NC. GARY S. CUDDEBACK is a professor at the University of North Carolina at Chapel Hill School of Social Work and a research fellow at the Cecil G. Sheps Center for Health Services Research.Next >