Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders

OBJECTIVE: Although several treatments for adolescent substance abuse have been identified as promising by reviewers and federal agencies, treatment effects extending beyond 12 months have not been demonstrated in randomized clinical trials. The primary purpose of this report was to examine the 4-year outcomes of an evidence-based treatment of substance-abusing juvenile offenders. METHOD: Eighty of 118 substance-abusing juvenile offenders participated in a follow-up 4 years after taking part in a randomized clinical trial comparing multisystemic therapy (MST) with usual community services. A multimethod (self-report, biological, and archival measures) assessment battery was used to measure the criminal behavior, illicit drug use, and psychiatric symptoms of the participating young adults. RESULTS: Analyses demonstrated significant long-term treatment effects for aggressive criminal activity (0.15 versus 0.57 convictions per year) but not for property crimes. Findings for illicit drug use were mixed, with biological measures indicating significantly higher rates of marijuana abstinence for MST participants (55% versus 28% of young adults). Long-term treatment effects were not observed for psychiatric symptoms. CONCLUSIONS: Findings provide some support for the long-term effectiveness of an evidenced-based family-oriented treatment of substance-abusing juvenile offenders. The clinical, research, and policy implications of these findings are noted.     

A SAMHSA research initiative assessing the effectiveness of jail diversion programs for mentally ill persons

For nearly 30 years jail diversion programs have had wide support as a way to prevent people with mental illnesses and substance use disorders from unnecessarily entering the criminal justice system by providing more appropriate community-based treatment. Although these programs have had wide support, very few systematic outcomes studies have examined their effectiveness. This paper discusses findings on rates of incarceration of persons with serious mental illness and co-occurring substance use disorders in U.S. jails, summarizes recently completed research on jail diversion programs, and describes a three-year research initiative begun in 1997 by the Substance Abuse and Mental Health Services Administration that uses a standardized protocol to examine the characteristics and outcomes of various types of jail diversion programs in nine sites throughout the U.S.     

Psychiatric comorbidity and the 16-month trajectory of substance-abusing and substance-dependent juvenile offenders.

OBJECTIVES: To examine the concurrent correlates of internalizing and externalizing disorders among substance-abusing and substance-dependent juvenile offenders and to determine the association between psychiatric comorbidity and psychosocial functioning of the youths 16 months later. METHOD: Participants were 118 juvenile offenders meeting DSM-III-R criteria for substance abuse or dependence and their families. A multisource measurement battery was used to assess drug use, criminal activity, family relations, peer relations, school functioning, and out-of-home placements. RESULTS: Comorbidity for externalizing disorders was associated with high rates of antisocial behavior and predicted worse 16-month outcomes than substance abuse alone or substance abuse with comorbid internalizing disorders. For criminal activity and drug use, the presence of internalizing disorders buffered the deleterious effect of externalizing disorders on substance-abusing and substance-dependent juvenile offenders. CONCLUSIONS: Even in substance-abusing delinquents, a population already extreme in antisocial behavior, the presence of externalizing disorders indicates high risk for deterioration.     

Juveniles in court

Nineteenth-century American reformers were concerned about the influence of immaturity and development in juvenile offenses. They responded to their delinquent youths through the creation of juvenile courts. This early American juvenile justice system sought to treat children as different from adults and to rehabilitate wayward youths through the state's assumption of a parental role. Although these rehabilitative goals were never fully realized, the field of American child psychiatry was spawned from these efforts on behalf of delinquent youths. Early child psychiatrists began by caring for juvenile offenders. The function of a child psychiatrist with juvenile delinquents expanded beyond strictly rehabilitation, however, as juvenile courts evolved to resemble criminal adult courts-due to landmark Supreme Court decisions and also juvenile legislation between 1966 and 1975. In response to dramatically increased juvenile violence and delinquency rates in the 1980s, juvenile justice became more retributional, and society was forced to confront issues such as capital punishment for juveniles, their transfer to adult courts, and their competency to stand trial. In the modern juvenile court, child psychiatrists are often asked to participate in the consideration of such issues because of their expertise in development. In that context we review the role of psychiatrists in assisting juvenile courts.     

Effectiveness of a mental health court in reducing criminal recidivism and violence

OBJECTIVE: In response to the large-scale involvement of people with mental disorders in the criminal justice system, many communities have created specialized mental health courts in recent years. However, little research has been done to evaluate the criminal justice outcomes of such courts. This study evaluated whether a mental health court can reduce the risk of recidivism and violence by people with mental disorders who have been arrested. METHOD: A retrospective observational design was used to compare the occurrence of new criminal charges for 170 people who entered a mental health court after arrest and 8,067 other adults with mental disorders who were booked into an urban county jail after arrest during the same interval. A matching strategy based on propensity scores was used to adjust analyses for nonrandom selection into mental health court. RESULTS: Propensity-weighted Cox regression analysis, controlling for other potential confounding variables (demographic characteristics, clinical variables, and criminal history), showed that participation in the mental health court program was associated with longer time without any new criminal charges or new charges for violent crimes. Successful completion of the mental health court program was associated with maintenance of reductions in recidivism and violence after graduates were no longer under supervision of the mental health court. CONCLUSIONS: The results indicate that a mental health court can reduce recidivism and violence by people with mental disorders who are involved in the criminal justice system.     

Symptoms of Depression and Successful Drug Court Completion

The majority of drug abusing offenders who need substance abuse treatment do not receive it. Although interventions like drug court increase the probability of offender success, little is known about how co-occurring psychological symptoms impact drug court treatment outcomes. Based on previous research, we hypothesized that co-occurring psychological symptoms would have a significant relationship with successful drug court completion. Using a sample of suburban drug court enrollees (n = 122), multivariate logistic regression was conducted with successful drug court completion as the outcome variable. Predictor variables included symptom counts of depression, post-traumatic stress, obsessive–compulsive disorder, panic disorder, psychosis, generalized anxiety, and social phobia. Results indicated that participants with fewer symptoms of depression were more likely to successfully complete drug court than participants with more symptoms. The present study extends previous research by demonstrating that symptoms of depression are related to poorer outcomes for drug court enrollees. Accordingly, drug courts need to address participants’ symptoms of depression to maximize success.     

A National Study of Veterans Treatment Court Participants: Who Benefits and Who Recidivates

Although there are now over 400 veterans treatment courts (VTCs) in the country, there have been few studies on participant outcomes in functional domains. Using national data on 7931 veterans in the Veterans Affairs (VA) Veterans Justice Outreach program across 115 VA sites who entered a VTC from 2011 to 2015, we examined the housing, employment, income, and criminal justice outcomes of VTC participants; and identified veteran characteristics predictive of outcomes. VTC participants spent an average of nearly a year in the program and 14% experienced a new incarceration. From program admission to exit, 10% more participants were in their own housing, 12% more were receiving VA benefits, but only 1% more were employed. Controlling for background characteristics, a history of incarceration predicted poor criminal justice, housing, and employment outcomes. Participants with property offenses or probation/parole violations and those with substance use disorders were more likely to experience a new incarceration. Participants with more mental health problems were more likely to be receiving VA benefits and less likely to be employed at program exit. Together, these findings highlight the importance of proper substance abuse treatment as well as employment services for VTC participants so that they can benefit from the diversion process.     

Factors in disproportionate representation among persons recommended by programs and accepted by courts for jail diversion

OBJECTIVE: This study examined the decision-making process related to enrollment in jail diversion programs for people with mental illness. The examination explored the activities of diversion programs and courts related to determinations of whether individuals were appropriate for diversion: activities included jail screenings, clinical and criminal justice assessments, psychiatric evaluations, and court reviews of diversion plans. Factors associated with program recommendation decisions and court acceptance decisions were also examined. METHODS: The study included data from a multisite, federally funded jail diversion initiative. Conditional logistic regression models were employed to determine which factors influenced both program and court decision making. RESULTS: A total of 34,832 activities resulted in a program decision regarding diversion eligibility (N=32,917) or a court decision regarding acceptance of the diversion plan (N=1,915). Compared with the national arrestee population, those referred for diversion had a greater proportion of women, whites, and older persons and a lower proportion of persons with felony and violence charges. Regression analyses indicated that women and persons with nonviolent and nonfelony charges were more likely to be recommended for diversion by programs. These decisions were also influenced by interactions between legal and nonlegal factors. Individuals with nonfelony offenses were more likely to be accepted by the courts. CONCLUSIONS: One major finding is the large number of front-end activities required to enroll a small number of jail diversion participants. A second finding is that disproportionate representation occurs early in the decision-making process. Both formal and informal factors influenced decision making. Overall the results suggest that jail diversion programs should examine their decision-making processes to ensure that all appropriate individuals are included in jail diversion.     

Pharmacotherapy for opioid addiction in community corrections

Abstract

Pharmacotherapy for opioid addiction with methadone, buprenorphine, and naltrexone has proven efficacy in reducing illicit opioid use. These treatments are under-utilized among opioid-addicted individuals on parole, probation, or in drug courts. This paper examines the peer-reviewed literature on the effectiveness of pharmacotherapy for opioid addiction of adults under community-based criminal justice supervision in the US. Compared to general populations, there are relatively few papers addressing the separate impact of pharmacotherapy on individuals under community supervision. Tentative conclusions can be drawn from the extant literature. Reasonable evidence exists that illicit opioid use and self-reported criminal behaviour decline after treatment entry, and that these outcomes are as favourable among individuals under criminal justice supervision as the general treatment population. Surprisingly, there is no conclusive evidence regarding the extent to which pharmacotherapy impacts the likelihood of arrest and incarceration among individuals under supervision. However, given the proven efficacy of these three medications in reducing illicit opioid use and the evidence that, in the general population, methadone and buprenorphine treatment are associated with reduction in overdose mortality, the use of all three pharmacotherapies among patients under criminal justice supervision should be expanded while more data are collected on their impact on arrest and incarceration.     

Treatment retention and outcome among cocaine-dependent patients with and without active criminal justice involvement

In this study, we examined differences between cocaine- and alcohol-dependent patients with and without active criminal justice involvement. Data were combined from two randomized controlled trials, in which 243 participants were randomly assigned to manual-guided behavioral therapies and medication (either disulfiram or placebo). Fifty-five (23%) participants of the combined sample had active criminal justice involvement, defined as being referred to treatment by a court official or a probation or parole officer. Regarding treatment outcome, there were no significant differences between participants with and without criminal justice involvement with regard to frequency of cocaine or other substance use during the three months of study treatment or the one-year follow-up. Although the criminal justice-referred group had significantly more new arrests during the one-year follow-up, when antisocial personality disorder was utilized as a covariate, there were no significant differences between criminal justice groups in number of arrests at the one-year follow-up. These data suggest that participants with active criminal justice involvement do not necessarily have poorer retention or substance use outcomes than do individuals who are self-referred or referred by other sources when treated in well-defined protocols.     

Juvenile justice mental health services

As the second century of partnership begins, child psychiatry and juvenile justice face continuing challenges in meeting the mental health needs of delinquents. The modern juvenile justice system is marked by a significantly higher volume of cases, with increasingly complicated multiproblem youths and families with comorbid medical, psychiatric, substance abuse disorders, multiple family and psychosocial adversities, and shrinking community resources and alternatives to confinement. The family court is faced with shrinking financial resources to support court-ordered placement and treatment programs in efforts to treat and rehabilitate youths. The recognition of high rates of mental disorders for incarcerated youth has prompted several recommendations for improvement and calls for reform [56,57]. In their 2000 annual report, the Coalition for Juvenile Justice advocated increased access to mental health services that provide a continuum of care tailored to the specific problems of incarcerated youth [58]. The specific recommendations of the report for mental health providers include the need for wraparound services, improved planning and coordination between agencies, and further research. The Department of Justice, Office of Juvenile Justice and Delinquency Prevention has set three priorities in dealing with the mental health needs of delinquents: further research on the prevalence of mental illness among juvenile offenders, development of mental health screening assessment protocols, and improved mental health services [59]. Other programs have called for earlier detection and diversion of troubled youth from juvenile justice to mental health systems [31,56]. Most recently, many juvenile and family courts have developed innovative programs to address specific problems such as truancy or substance use and diversionary or alternative sentencing programs to deal with first-time or nonviolent delinquents. All youths who come in contact with the juvenile justice system should be screened and, when necessary, assessed for mental health and substance abuse disorders. The screening should occur at the youth's earliest point of contact with the juvenile justice system and should be available at all stages of juvenile justice processing. Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system [58]. If delinquent youths do not receive the necessary evaluation, treatment, and rehabilitation, they face the real prospect of further incarceration in adult correctional facilities. Improved screening and treatment require better interagency collaboration, established standards of care, and continuing research on the mental health needs of youth in the juvenile justice system. Better mental health care for youth in the juvenile justice system supports the goal of rehabilitation. Mental health professionals should support these efforts as the appropriate response to meet the challenges of the new century.     

Adaptive interventions may optimize outcomes in drug courts: A pilot study

Adaptive interventions apply a priori decision rules for adjusting treatment services in response to participants’ clinical presentation or performance in treatment. This pilot study (n = 30) experimentally examined an adaptive intervention in a misdemeanor drug court. The participants were primarily charged with possession of marijuana (73%) or possession of drug paraphernalia (23%). Results revealed that participants in the adaptive condition had higher graduation rates and required significantly less time to graduate from the program and achieve a final resolution of the case. It took an average of nearly 4 fewer months for participants in the adaptive intervention to resolve their cases compared with those participating in drug court as usual. Participants in the adaptive condition also reported equivalent satisfaction with the program and therapeutic alliances with their counselors. These data suggest that adaptive interventions may enhance the efficiency and effectiveness of drug courts and justify examining adaptive interventions in large-scale drug court studies.     

Contemporary addiction treatment: a review of systems problems for adults and adolescents.

There is national concern regarding the problems of alcohol and drug abuse and the adequacy and quality of the national addiction treatment system, particularly for adolescents. This article reviews the published literature evaluating the ability of health, education, and specialty treatment systems to identify and treat affected adolescents and adults. A separate section reviews the status of the national treatment system for adults through findings from a nationally representative survey of 175 specialty treatment programs. The findings are unambiguous and disturbing. Although substance abuse is prevalent in most schools, primary care practices, mental health clinics, and criminal justice agencies, there is insufficient training, organization, or reimbursement to screen, assess, and refer those with dependence or abuse disorders to appropriate services. There are too few programs available to treat those substance-dependent patients who are screened and significant barriers for patients attempting to enter those programs. Finally, the organizational, administrative, and personnel infrastructures of many treatment programs are fragile and unstable, making them unable to implement evidence-based care. These problems are serious in the adult system and even worse in the adolescent system. The article concludes with suggestions for improving systems integration to improve the quantity and quality of available care.     

Impact of program services on treatment outcomes of patients with comorbid mental and substance use disorders

OBJECTIVE: This study examined the outcomes of individuals with co-occurring disorders who received drug treatment in programs that varied in their integration of mental health services. Patients treated in programs that provided more on-site mental health services and had staff with specialized training were expected to report less substance use and better psychological outcomes at follow-up. METHODS: Participants with co-occurring disorders were sampled from 11 residential drug abuse treatment programs for adults in Los Angeles County. In-depth assessments of 351 patients were conducted at treatment entry and at follow-up six months later. Surveys conducted with program administrators provided information on program characteristics. Latent variable structural equation models revealed relationships of patient characteristics and program services with drug use and psychological functioning at follow-up. RESULTS: Individuals treated in programs that provided specific dual diagnosis services subsequently had higher rates of utilizing mental health services over six months and, in turn, showed significantly greater improvements in psychological functioning (as measured by the Brief Symptom Inventory and the RAND Health Survey 36-item short form) at follow-up. More use of psychological services was also associated with less heroin use at follow-up. African Americans reported poorer levels of psychological functioning than others at both time points and were less likely to be treated in programs that provided mental health services. CONCLUSIONS: Study findings support continued efforts to provide specialized services for individuals with co-occurring disorders within substance abuse treatment programs as well as the need to address additional barriers to obtaining these services among African Americans.     

Targeting Criminal Recidivism in Mentally Ill Offenders: Structured Clinical Approaches

Decreasing criminal recidivism in justice-involved individuals with mental illness, is among the most consistently desired outcomes by programs, policy makers and funding agencies. Evidencebased practices with track records of effectiveness in treating mental illness and co-occurring substance abuse, while important clinically, do not necessarily address criminal recidivism. Addressing recidivism, therefore, may require a more targeted criminal justice focus. In this paper, we describe recent challenges to decriminalization approaches and review factors associated with recurrent criminal behavior. In particular, we focus on structured clinical interventions which were created or adapted to target the thoughts and behaviors associated with criminal justice contact.     

Psychotherapy and science - harmony or dissonance?

Clinical practice and psychotherapy research are often perceived as areas of conflict with little common ground. Despite substantial empirical progress over the last few decades, research findings frequently play only a minor role in clinical decision making or treatment selection. Instead, clinical psychologists often trust their own clinical judgment, which may lead, for example, to an underestimation of the likelihood of treatment failures. In clinical practice, flexible treatments are often preferred over standardized interventions, based, for example, on the assumption that the latter ones will not be accepted by clinical patients. However, in addition to providing compelling evidence for their effectiveness, recent data suggest that patients highly appreciate standardized interventions such as structured clinical interviews. Recent research has shown that research-oriented training programs enhance the acceptance of evidence-based treatments by therapists as well as therapeutic outcomes. To facilitate the dissemination of research findings, psychotherapy researchers need to make their findings more easily accessible to practitioners, and training programs for clinical psychologists should be research based.     

Competency to stand trial in family court: characteristics of competent and incompetent juveniles

Competency to stand trial (CST) has been among the most thoroughly researched psycholegal issues in the past 20 years. However, little attention has been given to CST in juveniles facing delinquency or criminal proceedings. In a sample of 112 pretrial juvenile defendants undergoing court-ordered CST evaluations, 14 percent of the sample was judged incompetent to stand trial (IST). Sixty-one (55%) were considered to have one or more examiner-cited competency deficits that might lead the court to a finding of IST. Only age, intelligence level, and history of previous juvenile arrest differentiated competent from incompetent juveniles. Implications of the results for raising the CST issue in family or circuit courts are discussed as are suggestions for future research.     

Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study.

OBJECTIVE: The study examined the association between fidelity of programs to the assertive community treatment model and client outcomes in dual disorders programs. METHODS: Assertive community treatment programs in the New Hampshire dual disorders study were classified as low-fidelity programs (three programs) or high-fidelity programs (four programs) based on extensive longitudinal process data. The study included 87 clients with a dual diagnosis of severe mental illness and a comorbid substance use disorder. Sixty-one clients were in the high-fidelity programs, and 26 were in the low-fidelity programs. Client outcomes were examined in the domains of substance abuse, housing, psychiatric symptoms, functional status, and quality of life, based on interviews conducted every six months for three years. RESULTS: Clients in the high-fidelity assertive community treatment programs showed greater reductions in alcohol and drug use and attained higher rates of remission from substance use disorders than clients in the low-fidelity programs. Clients in high-fidelity programs had higher rates of retention in treatment and fewer hospital admissions than those in low-fidelity programs. No differences between groups were found in length of hospital stays and other residential measures, psychiatric symptoms, family and social relations, satisfaction with services, and overall life satisfaction. CONCLUSIONS: Faithful implementation of, and adherence to, the assertive community treatment model for persons with dual disorders was associated with superior outcomes in the substance use domain. The findings underscore the value of measures of model fidelity, and they suggest that local modifications of the assertive community treatment model or failure to comply with it may jeopardize program success.