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.     

An evaluation of a mental health program for homeless men

The authors report the results of a before-and-after evaluation of an on-site mental health day treatment program for homeless men. Thirty-two subjects were interviewed 6 or more months after placement from a crisis shelter to community housing in order to probe housing stability, aftercare treatment compliance, employment, rehospitalization, and criminal justice contacts. In the after phase, living on the street was virtually eliminated, use of shelters decreased sevenfold, aftercare utilization tripled, and contacts with the criminal justice system were halved. Psychiatric hospitalizations and unemployment were higher in the after phase. Findings are discussed in relation to the need to conduct controlled experiments of new psychosocial treatments for the homeless mentally ill.     

Childhood risk factors for criminal justice involvement in a sample of homeless people with serious mental illness

It has been suggested that criminal justice involvement among the homeless, particularly those with mental illness, is largely situational. The objective of this study was to assess, in a sample of homeless seriously mentally ill people, the prevalence of childhood conduct disorder behaviors as a risk factor for adult criminal activity as well as the extent and types of adult criminal justice contact. Data were taken from the national ACCESS program, which conducted extensive baseline interviews with 7,222 homeless seriously mentally ill adults. The interview assessed demographics, childhood risk factors for criminal activity such as conduct disorder behaviors, foster care, and parental abuse, as well as current illness severity and recent criminal justice contact. The 2-month arrest rate in this sample was much higher than national rates (11% compared with 1% annually in the general population). Although most arrests were for minor crimes (10.8%), there were also substantial rates of arrest for major (2.7%) and substance-related charges (2.0%). The prevalence of a history of conduct disorder behavior was also substantial (55% in male subjects, 40% in female subjects), and conduct disorder was a strong predictor of recent criminal justice involvement, even after controlling for other predictors of arrest (odds ratio = 1.76 for major crimes, 1.49 for minor crimes, and 1.98 for substance-related crimes). Recent literature has criticized a trend to criminalize homeless mentally ill persons for attempting to get needed food, shelter, or medical attention. However, these data indicate that at least some proportion of arrests in this population are of people who have been exhibiting antisocial behavior since early adolescence, and that early antisocial behavior is a strong predictor of all types of recent arrests in this population.     

Criminal history as a prognostic indicator in the treatment of homeless people with severe mental illness

OBJECTIVE: This study examined the clinical problems and treatment outcomes of homeless people with severe mental illness and a history of incarceration. METHODS: Between May 1994 and June 1998, a total of 5,774 people entered assertive community treatment case management services in the Access to Community Care and Effective Services and Supports (ACCESS) demonstration program at 18 sites in nine states. This study used data from reassessments at 12 months after program entry. Analysis of variance was used to compare baseline status and 12-month outcomes for clients with a lifetime incarceration history of less than six months, of six months or more, and no incarceration history. The outcomes assessed were housing status, employment status, psychiatric problems, alcohol problems, drug problems, and criminal justice involvement. RESULTS: Two-thirds of the ACCESS clients had a history of incarceration, with about one-third having less than six months of incarceration and about one-third having six months or more of incarceration. Clients with a long-term incarceration history had higher psychiatric symptom scores, higher drug use and alcohol use scores, and higher levels of dual diagnosis than those with a short-term incarceration history or those with no history of incarceration. The same order of differences was found on measures of childhood abuse, family-of-origin stability, and childhood conduct disorder. Clients with an incarceration history of six months or more reported higher levels of long-term homelessness than the group without an incarceration history. The group with an incarceration history of less than six months showed less improvement at the 12-month follow-up evaluation than the group with no incarceration history on only one outcome measure, psychiatric problems. The group with an incarceration history of six months or more had poorer outcomes than the group with no incarceration history on only two of six outcomes, psychiatric problems and number of days in jail. CONCLUSIONS: This study found that among homeless clients with severe mental illness, clients with a history of incarceration have more serious problems and show somewhat less improvement in some community adjustment domains.     

Jail incarceration, homelessness, and mental health: a national study

OBJECTIVE: This study sought to investigate the rates and correlates of homelessness, especially mental illness, among adult jail inmates. METHODS: Data from a national survey of jail inmates (N=6,953) were used to compare the proportion of jail inmates who had been homeless in the previous year with the proportion of persons in the general population who had been homeless in the previous year, after standardization to the age, race and ethnicity, and gender distribution of the jail sample. Logistic regression was then used to examine the extent to which homelessness among jail inmates was associated with factors such as symptoms or treatment of mental illness, previous criminal justice involvement, specific recent crimes, and demographic characteristics. RESULTS: Inmates who had been homeless (that is, those who reported an episode of homelessness anytime in the year before incarceration) made up 15.3% of the U.S. jail population, or 7.5 to 11.3 times the standardized estimate of 1.36% to 2.03% in the general U.S. adult population. In comparison with other inmates, those who had been homeless were more likely to be currently incarcerated for a property crime, but they were also more likely to have past criminal justice system involvement for both nonviolent and violent offenses, to have mental health and substance abuse problems, to be less educated, and to be unemployed. CONCLUSIONS: Recent homelessness was 7.5 to 11.3 times more common among jail inmates than in the general population. Homelessness and incarceration appear to increase the risk of each other, and these factors seem to be mediated by mental illness and substance abuse, as well as by disadvantageous sociodemographic characteristics.     

Homeless near a thousand homes: outcomes of homeless youth in a crisis shelter

Clients who received crisis services at a homeless shelter for transition-aged youth were recruited for a study to describe the youth served, to track outcomes of care, and to examine factors associated with differing outcomes. Participants were 202 men and women who completed a battery of interviews and self-report measures at intake and at 3 follow-up points. Youth served had experienced high levels of adversity and trauma and typically had poor educational and vocational preparation. A multidisciplinary array of services was provided, and overall, participants showed significant improvement from intake to discharge and in the 6 months after discharge. Background, service, and psychological factors did not predict housing outcomes. Better vocational outcome was associated with more recent work experience. Results point to the need for providers of services to the homeless to be aware of the distinct needs and characteristics of transition-aged youth.     

Homelessness and predictors of criminal reoffending: A retrospective cohort study

Background

There are not many longitudinal studies examining people experiencing homelessness and interacting with the criminal justice system over time.

Aims

To describe the type of criminal offences committed, court outcomes, identify probable predictors of reoffending, and estimate the criminal justice costs in a cohort of homeless hostel clinic attendees.

Method

A retrospective cohort study of 1646 people attending a homeless clinic who had had contact with the criminal justice system (CJS) in New South Wales (NSW), Australia, using linked clinic, criminal offence, health and mortality data from 1 July 2008 to 30 June 2021. Initial comparisons were made with the 852 clinic attendees without CJS contact in the period. Multivariable logistic regression was used to identify predictors of recidivism.

Results

There were 16,840 offending episodes, giving an offence rate of 87.8 per 100 person-years (95%CI: 86.5–89.1). The most common index offences were acts intended to cause injury (22%), illicit drug (17%) and theft-related (12%) offences. Most people (83%) were found guilty of the index offence and received a fine (37%) or community-based sentence (29%). Total court finalisation costs were AUD $11.3 million. Three-quarters of those convicted reoffended within 24 months. Offenders were more likely to be younger, have a diagnosis of personality disorder (AOR: 1.31; 95% CI: 1.04–1.67), a substance use disorder (AOR: 1.60; 95% CI 1.14–2.23) and/or to have a previous charge dismissed on mental health grounds (AOR: 1.79; 95% CI: 1.31–2.46). Within the offending cohort, reoffenders had almost twice the odds of having theft-related offences as their principal index offence (AOR: 1.85; 95% CI: 1.29–2.66).

Conclusions

This longitudinal study finding of not only a high rate of criminal justice contact, but also a high rate of recidivism among people who have been homeless, lends support to a need for strategies both to address the root causes of homelessness and to provide a comprehensive systems-based response to reduce recidivism, that includes secure housing as well as mental health and substance use treatment programmes for homeless offenders.     

Outcomes and service use among homeless persons with serious mental illness and substance abuse

OBJECTIVE: This study compared baseline characteristics and clinical improvement after 12 months among homeless persons with a diagnosis of serious mental illness with and without a comorbid substance use disorder. METHODS: The study subjects were 5,432 homeless persons with mental illness who were participating in the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program. Analysis of covariance was used to compare clients who had dual diagnoses and those who did not and to identify any association between service use and clinical improvement. RESULTS: Follow-up data were available for 4,415 clients (81 percent). At baseline, clients with dual diagnoses were worse off than those without dual diagnoses on most clinical and social adjustment measures. Clients with dual diagnoses also had poorer outcomes at follow-up on 15 (62 percent) of 24 outcome measures. However, among clients with dual diagnoses, those who reported extensive participation in substance abuse treatment showed clinical improvement comparable to or better than that of clients without dual diagnoses. On measures of alcohol problems, clients with dual diagnoses who had a high rate of participation in self-help groups had outcomes superior to those of other clients with dual diagnoses. Clients with dual diagnoses who received high levels of professional services also had superior outcomes in terms of social support and involvement in the criminal justice system. CONCLUSIONS: Homeless persons with dual diagnoses had poorer adjustment on most baseline measures and experienced significantly less clinical improvement than those without dual diagnoses. However, those with dual diagnoses who received extensive substance abuse treatment showed improvement similar to those without at 12 months.     

Are jails replacing the mental health system for the homeless mentally ill?

The author explores the process of how homeless mentally ill persons become involved with the criminal justice system. The unique demands of homelessness and chronic mental illness were specifically examined in this naturalistically based study. The author concludes that a combination of severe mental illness, a tendency to decompensate in a nonstructured environment, and an inability or unwillingness to follow through with aftercare contributed to involvement with the criminal justice system. Changes in the mental health system that would prevent the criminalization of the homeless mentally ill are suggested.This paper is based in part on research supported by grant #717632 from the Office of Program Evaluation and Research, Ohio Department of Mental Health.     

Explaining Homeless Youths’ Criminal Justice Interactions: Childhood Trauma or Surviving Life on the Streets?

Homeless youth are at increased risk for involvement in the criminal justice system. This study investigated childhood trauma as a risk factor for arrest or jail among a sample of youth seeking services at drop in, shelter, and transitional housing settings, while controlling for more established risk factors including: substance use, peer deviance, and engagement in survival behaviors. Standardized and researcher developed measures collected quantitative data through face-to-face interviews with youth (N = 202). Two sequential logic regression models identified significant predictors of arrest and jail, with a particular interest in the effects of childhood maltreatment. Youth with a history of physical abuse were nearly twice as likely to be arrested and to be jailed compared to non-abused youth, controlling for the significant influence of drug use and survival behaviors. These findings suggest the need for trauma screening and trauma-informed services for homeless youth at risk of illegal behavior.     

Prediction of homelessness within three months of discharge among inpatients with schizophrenia.

OBJECTIVE: The authors' goal was to identify factors that place inpatients with schizophrenia at risk of becoming homeless after hospital discharge. METHODS: Patients with schizophrenia or schizoaffective disorder (N=263) were assessed at discharge from general hospitals in New York City and reassessed three months later to evaluate whether they had become homeless. Sociodemographic and clinical characteristics associated with homelessness were identified using likelihood ratio chi square analysis and logistic regression. RESULTS: Twenty patients (7.6 percent) reported an episode of homelessness during the follow-up period. Patients who had a drug use disorder at hospital discharge were significantly more likely to report becoming homeless than those without a drug use disorder. Patients with a total score above 40 on the Brief Psychiatric Rating Scale (BPRS) at hospital discharge were more likely to report becoming homeless than patients with lower scores, as were those with Global Assessment Scores less than 43. Twelve of 30 patients with a drug use disorder, a BPRS score above 40, and a GAS score less than 43 at hospital discharge reported becoming homeless. CONCLUSIONS: The combination of a drug use disorder, persistent psychiatric symptoms, and impaired global functioning at the time of hospital discharge poses a substantial short-term risk of homelessness among patients with schizophrenia. Patients who fit this profile may be candidates for community-based programs that are specifically aimed at preventing homelessness among patients with severe mental illness.     

Housing placement and subsequent days homeless among formerly homeless adults with mental illness.

OBJECTIVE: The study examined the influence of group or individual housing placement and consumer characteristics on the number of days subsequently homeless among formerly homeless mentally ill persons. METHODS: A total of 303 homeless shelter residents with severe mental illness were screened for dangerousness, 118 were randomly assigned to either independent apartment or staffed group living sites, and 110 were followed for 18 months. Study participants' sociodemographic characteristics, diagnosis, and residential preferences and the residential recommendations made by clinicians were measured at baseline. RESULTS: Overall, 76 percent of the study participants were housed at the end of the 18-month follow-up period, although 27 percent had experienced at least one episode of homelessness during the period. The number of days homeless was greater for individuals assigned to independent apartments than for those placed in staffed group homes, but only for members of minority groups. Substance abuse was the strongest individual-level predictor of days homeless. Individuals whom clinicians identified as needing group living experienced more days homeless, irrespective of the type of housing they received. Consumers who stated a strong preference for independent living had more days homeless than those who were amenable to staffed group homes. CONCLUSIONS: Although consumers more frequently prefer independent living, placement in staffed group housing resulted in somewhat fewer days homeless for some groups of consumers. Further experience of homelessness by formerly homeless mentally ill individuals may be reduced by providing effective substance abuse treatment and by paying special attention to consumers identified by clinicians to be at particular risk for housing loss.     

Incarceration associated with homelessness, mental disorder, and co-occurring substance abuse

OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-related disorders were held in jail longer than other inmates who had been charged with similar crimes. CONCLUSIONS: People who were homeless and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.     

Factors predicting arrest for homeless persons receiving integrated residential treatment for co‐occurring disorders

Background Homeless individuals are at increased risk for health and criminal justice problems. Aims The aim of this study was to examine risk factors affecting arrest rates in a cohort of homeless people with co‐occurring psychiatric and substance‐abuse disorders. Methods Baseline data were collected from 96 homeless individuals residing in a residential treatment facility for people with co‐occurring disorders. Arrest data were obtained for 2 years following treatment intake. Regression analyses were employed to examine interactions between study variables. Results One third of the sample was arrested during the 2‐year follow‐up period, principally for drug offences. People referred to treatment directly from the criminal justice system were four times more likely to re‐offend than those referred from other sources. Participants' perceived need for mental‐health services reduced risk of arrest while their perception of medical needs increased this risk. Conclusions The relationship between referral from a criminal justice source and re‐arrest after admission to the treatment facility is unsurprising, and consistent with previous literature, but the suggestion of an independently increased risk in the presence of perceived physical health‐care needs is worthy of further study. The lower risk of arrest for people who perceive that they have psychological needs is encouraging. Copyright © 2009 John Wiley & Sons, Ltd.     

Clinical Indicators of Successful Substance Use Treatment among Adults in the Criminal Justice System

A significant proportion of offenders in the criminal justice system require substance use treatment to foster desistance from criminal activities. Optimization of treatment outcomes is vital to reducing criminal justice involvement, especially post-treatment arrest. The current study examined clinical risk factors and their relationship with post-treatment recovery and arrest within the Comprehensive Assessment and Treatment Outcome (CATOR) system, the largest independent evaluation service of substance use treatment programs across the United States.Multivariate logistic regression analyses determined that patients who were younger, male, and received a drug dependence diagnosis as opposed to alcohol dependence were more likely to be arrested within one-year of discharge from treatment. Additionally, patients who relapsed were more than two and a half times as likely to be arrested within one year of treatment discharge compared to those who did not relapse (OR = 2.70, 95 % C.I. = 2.05–3.54, Wald’s χ² = 51.16).The findings from this research have far-reaching implications for treatment programs designed specifically for patients involved in the criminal justice system.     

Homelessness and drug abuse among young men who have sex with men in New York city: a preliminary epidemiological trajectory

The objective of this paper is to profile the role of homelessness in drug and sexual risk in a population of young men who have sex with men (YMSM). Data are from a cross-sectional survey collected between 2000 and 2001 in New York City (N = 569). With the goal of examining the import of homelessness in increased risk for the onset of drug and sexual risk, we compare and contrast three subgroups: (1) YMSM with no history of homelessness, (2) YMSM with a past history of homelessness but who were not homeless at the time of the interview, and (3) YMSM who were currently homeless. For each group, we describe the prevalence of a broad range of stressful life events (including foster care and runaway episodes, involvement in the criminal justice system, etc.), as well as selected mental health problems (including past suicide attempts, current depression, and selected help-seeking variables). Additionally, we examine the prevalence of selected drug and sexual risk, including exposure to a broad range of illegal substances, current use of illegal drugs, and prevalence of lifetime exposure to sex work. Finally, we use an event history analysis approach (time-event displays and paired t-test analysis) to examine the timing of negative life experiences and homelessness relative to the onset of drug and sexual risk. High levels of background negative life experiences and manifest mental health distress are seen in all three groups. Both a prior experience of homelessness and currently being homeless are both strongly associated with both higher levels of lifetime exposure to drug and sexual risk as well as higher levels of current drug and sexual risk. Onset of these risks occur earlier in both groups that have had an experience of housing instability (e.g., runaway, foster care, etc.) but are delayed or not present among YMSM with no history of housing instability. Few YMSM had used drug prior to becoming homeless. While causal inferences are subject to the limitations of a cross-sectional design, the findings pose an empirical challenge to the prevailing assumption that prior drug use is a dominant causal factor in YMSM becoming homeless. More broadly, the data illustrate the complexity of factors that must be accounted for, both in advancing our epidemiological understanding of the complexity of homelessness and its relationship to the onset of drug and sexual risk among high risk youth populations.     

Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness

OBJECTIVES: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. METHOD:S: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. RESULTS: Over the study period, the critical time intervention group and the usual services group incurred mean costs of 52,374 dollars and 51,649 dollars, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value--the additional price society is willing to spend for an additional nonhomeless night--greater than 152 dollars, the critical time intervention group exhibited a significantly greater net housing stability benefit, indicating cost-effectiveness, compared with usual care. CONCLUSION:S: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.     

Forensic assertive community treatment: preventing incarceration of adults with severe mental illness

OBJECTIVE: Persons with severe mental illness are overrepresented in jails and prisons in the United States. A national survey was conducted to identify assertive community treatment programs that have been modified to prevent arrest and incarceration of adults with severe mental illness who have been involved with the criminal justice system. METHODS: Members of the National Association of County Behavioral Health Directors (NACBHD) were surveyed to identify assertive community treatment programs serving persons with criminal justice histories and working closely with criminal justice agencies. Programs were identified that met three study criteria: all enrollees had a history of involvement with the criminal justice system, a criminal justice agency was the primary referral source, and a close partnership existed with a criminal justice agency to perform jail diversion. Senior representatives of each program were subsequently contacted, and a telephone survey was administered to gather information about the design and operation of the programs. RESULTS: A total of 291 of 314 NACBHD members (93 percent) responded to the survey. Sixteen programs that met the study criteria were identified in nine states. The primary referral sources for 13 of these programs (81 percent) were local jails. Eleven programs (69 percent) incorporated probation officers as members of their assertive community treatment teams. Eight programs (50 percent) had a supervised residential component, with five providing residentially based addiction treatment. Eleven of the 16 programs have begun operating since 1999. Only three programs have published outcome data on program effectiveness. CONCLUSIONS: Forensic assertive community treatment is an emerging model for preventing arrest and incarceration of adults with severe mental illness who have substantial histories of involvement with the criminal justice system. Further research is needed to establish the structure, function, and effectiveness of this developing model of service delivery.     

Outcomes of homeless adults with mental illness in a housing program and in case management only

OBJECTIVE: The effectiveness of two types of service programs in ameliorating homelessness among individuals with severe mental illness was compared. METHODS: Homeless persons with severe mental illness were recruited into the study on their entry into one of two types of homeless service programs. The first was a comprehensive housing program, in which consumers received guaranteed access to housing, housing support services, and case management. The second was a program of case management only, in which consumers received specialized case management services. In a quasi-experimental or nonrandom-assignment design, participants responded to instruments measuring housing status, mental health symptoms, substance use, physical health, and quality of life at baseline (program entry) and at six months and 12 months after entry. The baseline interview was completed by 152 participants and at least one of the two follow-up interviews by 108 participants. High-, medium-, and low-impairment subgroups, based on psychiatric symptoms and degree of alcohol and illegal drug use, were formed by means of a propensity score subclassification. RESULTS: Persons with high psychiatric symptom severity and high substance use achieved better housing outcomes with the comprehensive housing program than with case management alone. However, persons with low and medium symptom severity and low levels of alcohol and drug use did just as well with case management alone. CONCLUSIONS: The results suggest that the effectiveness, and ultimately the cost, of homeless services can be improved by matching the type of service to the consumer's level of psychiatric impairment and substance use rather than by treating mentally ill homeless persons as a homogeneous group.