Randomized trial of a reentry modified therapeutic community for offenders with co-occurring disorders: crime outcomes

This article describes a randomized study to determine the effectiveness of a reentry modified therapeutic community (RMTC) for offenders with co-occurring substance use and mental disorders (co-occurring disorders or COD). Men with COD, approved for community corrections placement postrelease, were recruited from nine Colorado prisons and stratified according to the type of treatment received while incarcerated (i.e., a prison modified therapeutic community [MTC] program or standard care). When released, each offender was randomly assigned either to the experimental RMTC (E-RMTC) condition (n = 71) or to the control parole supervision and case management (PSCM) condition (n = 56). An intent-to-treat analysis 12 months postprison release showed that the E-RMTC participants were significantly less likely to be reincarcerated (19% vs. 38%), with the greatest reduction in recidivism found for participants who received MTC treatment in both settings. These findings support the RMTC as a stand-alone intervention and provide initial evidence for integrated MTC programs in prison and in aftercare for offenders with COD.     

A cognitive behavioral therapy for co-occurring substance use and posttraumatic stress disorders

Co-occurring posttraumatic stress disorder (PTSD) is prevalent in addiction treatment programs and a risk factor for negative outcomes. Although interventions have been developed to address substance use and PTSD, treatment options are needed that are effective, well tolerated by patients, and potentially integrated with existing program services. This paper describes a cognitive behavioral therapy (CBT) for PTSD that was adapted from a treatment for persons with severe mental illnesses and PTSD in community mental health settings. The new adaptation is for patients in community addiction treatment with co-occurring PTSD and substance use disorders. In this study, 5 community therapists delivered the CBT for PTSD. Outcome data are available on 11 patients who were assessed at baseline, post-CBT treatment, and at a 3-month follow-up post-treatment. Primary outcomes were substance use, PTSD severity, and retention, of which all were favorable for patients receiving the CBT for PTSD.     

A dual diagnosis demonstration project: treatment outcomes and cost analysis

This article presents findings from an outpatient dual diagnosis demonstration project that investigated whether integrated treatment services for severely and persistently ill patients with co-occurring mental health and substance abuse disorders could result in improved outcomes and reduction of criminal justice and health care costs. Integrated treatment was defined as a simultaneous focus on both disorders through the provision of psychosocial rehabilitation, psychotherapeutic and psychopharmacologic treatment, and substance abuse recovery and relapse prevention by cross-trained staff. One hundred twenty six (126) patients with multiple DSM-IV Axis I and Axis II disorders were assessed on a variety of mental health, substance abuse, and quality of life measures at baseline and at six-month intervals up to three years post entry into treatment. Criminal justice and health care costs obtained from state and local databases were compared two years before and two years after initiation of treatment to determine cost differences. The study found statistically significant improvements in psychiatric symptoms, substance abuse, and quality of life outcomes. There were also decreases in criminal justice and acute and sub-acute mental health and alcohol and other drug (AOD) costs and increases in outpatient mental health and physical health care costs.     

When the Junk Disappeared: Historical Case of a Heroin Shortage

Abstract

Because of high drop out rates, it is important to determine if enhancing standard substance treatment services will impact treatment completion rates among those in need of specialized services who are involved in the criminal justice system. The purpose of this research was to understand the impact of providing mental health services and gender-specific services for women in a modified therapeutic community setting. In the study, those who received mental health services and/or gender-specific treatment services, in additional to the substance abuse services, had similar rates of treatment completion as compared to those who received only substance abuse services. Logistic regression results indicated that controlling for other variables, age and length of time using one's primary drug were the only statistically significant predictors of treatment completion. The results suggest that the treatment model described in this article is a potentially cost-effective method of maximizing existing resources for treating substance abusing criminal offenders in community-based treatment settings.     

Integrated versus parallel treatment of co-occurring psychiatric and substance use disorders

The study examines 1-year treatment outcomes of 216 individuals with co-occurring severe and persistent mental illness and substance use disorders who were assigned to an integrated or parallel treatment condition. Comparisons indicated that the integrated group achieved greater reductions in the incidence of psychiatric hospitalization and arrest. The results of this study support the enhanced effectiveness of integrated treatment in decreasing the use of higher cost crisis-oriented services in clients with severe mental illness and substance use disorders.     

Design of a behavioral health program for urban American Indian/Alaska Native youths: a community informed approach

American Indian/Alaska Native (AI/AN) urban youths experience significant mental health and substance use problems. However, culturally relevant treatment approaches that incorporate community perspectives within the urban setting are limited. This study analyzes community perspectives from AI/AN parents, AI/AN youths, and services providers within Los Angeles County. Information gathered was utilized to develop a needs assessment for AI/AN youths with mental health and substance use problems and to design a community-informed treatment approach. Nine focus groups and key informant interviews were conducted. The Los Angeles County community strongly expressed the need for providing urban AI/AN youths with traditional healing services and cultural activities within their treatment program. However, various barriers to accessing mental health and substance abuse treatment services were identified. An integrated treatment approach was subsequently designed as a result of input derived from community perspectives. The community believed that providing urban AI/AN youths with an integrated treatment approach has the potential to decrease the risk of mental health and substance abuse problems in addition to enhancing their cultural identity and self esteem.     

The promise of prison-based treatment for dually diagnosed inmates

The Stay'n Out therapeutic community was created 25 years ago, the first rigorously evaluated prison program that demonstrated recidivism reduction. Since then, there has been a growing appreciation for the recidivism-reducing benefit of substance abuse treatment and the general understanding has been reached that prison treatment for substance abuse is good for the public interest. A number of replicated outcome studies have led to increases in treatment capacity in most state correctional systems, primarily utilizing the therapeutic community model. In contrast, efforts to introduce treatment for offenders with co-occurring mental illness and substance abuse disorders (COD) are only beginning. This article describes developments in prison substance abuse treatment and reentry programs and offers some guiding observations from prison substance abuse treatment history that could facilitate the development of COD treatment. Lessons learned include that: public safety (i.e., recidivism reduction) is a primary goal; personal accountability as a basic treatment value facilitates cooperation between treatment and correctional staff; self-help approaches foster more ambitious treatment goals than just symptom reduction; and well-run treatment programs often ease the burden of correctional administration.     

Factors predicting substance dependence and psychotropic medication use among offenders in community corrections

Co-occurring substance abuse and mental illness is prevalent among criminal offenders, but little is known about risk factors for these co-occurring disorders (COD) in community corrections population. To identify risk factors for COD in community corrections offenders, we analyzed assessment data from 5,595 offenders maintained under community supervision at a substance use diversion program. Three groups, offenders with substance use disorders who were taking psychotropic medications (SUPM), offenders with a substance use disorder (SUD) only and controls were compared. Logistic regressions were used to identify predictors of SUPM versus SUD only and controls. SUPM status was predicted by being White or Female, having some medical insurance (private or government aided), being unemployed, prior history of abuse/trauma, and prior history of suicidal ideation or behavior. Offenders with substance use disorders and co-occurring psychiatric problems face salient social risk that may need to be targeted through integrated services.     

A randomized clinical trial of a therapeutic community treatment for female inmates: outcomes at 6 and 12 months after prison release

This random assignment study compared female offenders (n = 468) with substance use disorders in a prison therapeutic community program with those in a cognitive-behavioral intervention. The study demonstrates that all women benefitted from gender-sensitive prison treatment, but the therapeutic community was more effective in reducing drug use, criminal activity, and exposure to trauma and increasing mental health functioning and time until reincarceration during the year after prison. In addition, the ability to sustain and even improve behavior change after the women leave prison highlights the importance of providing accessible community-based continuity of mental health and substance abuse services during reentry.     

Treatment of patients with schizophrenia and substance abuse disorders

Approximately half of patients with schizophrenia have a lifetime diagnosis of substance abuse disorders. These dual diagnosis patients are more likely to have poorer outcomes, including more severe psychiatric symptoms with increased hospitalizations, higher utilization of services and frequent homelessness. Assessment and treatment of dually diagnosed patients has evolved over the last twenty years. To date, the strongest evidence for effective management of dual diagnosis patients has been utilization of integrated treatment services, which combines both mental health and substance abuse treatments concurrently. Strategies commonly used include a combination of pharmacological treatment, intensive case management, motivational interviewing, individual and group psychotherapy, and family participation. This chapter summarizes the treatment options available for this population.     

HIV risk reduction and service delivery strategies in criminal justice settings

Because of the HIV risk behaviors of substance abusers, particularly injection drug users and those who exchange sex for drugs, and the large numbers who are already infected with HIV or showing symptoms of AIDS, significant service delivery issues are associated with their criminal justice processing. Many strategies have been implemented in correctional settings in an effort to prevent and control the transmission of HIV. A number of these are for the purpose of lowering transmission risk in institutions, whereas others have been structured for the sake of offering prevention/intervention to inmates before they return to the free community. As such, prisons and jails represent opportune settings for HIV prevention and education. The most common HIV control/prevention/education strategies include mandatory testing of inmates for HIV, segregating infected inmates from the general prison population, establishing special health care units for HIV positive and AIDS symptomatic inmates, offering HIV prevention and risk reduction programs, and granting medical parole for the terminally ill. Because drug abuse treatment results in substantial declines in the use of heroin, cocaine, and other drugs, treatment per se can play a significant role in reducing the spread of HIV and AIDS among those coming to the attention of the criminal justice system. Most promising are continuous and integrated treatment services that are tied to the stages of correctional supervision: primary treatment while incarcerated; secondary treatment while on work release, halfway house or community supervision; and, tertiary treatment in ongoing aftercare.     

Gaging the impact of multiple substance use on community corrections involvement

Historically, research has demonstrated that multiple substance use, compared to single substance use, poses additional challenges for treatment throughout the continuum of care including referrals, interventions, and relapse prevention. However, it appears that this pattern cannot be easily generalized to all criminal justice settings as evidenced by mixed findings across criminal justice samples. The purpose of the current study is to investigate possible differences in legal and substance-related outcomes between multiple substance users and single substance users within a community corrections sample. Structured clinical interviews were conducted to divide 531 individuals under community corrections supervision into three groups including multiple substance users, single substance users, and non-substance users. Results indicated that while multiple substance users were arrested more frequently and had more problems with family members, there were no differences compared to their single substance using counterparts in terms of depressive disorders, anxiety disorders, or types of offense. These findings contrast with previous research on samples outside of community corrections suggesting that multiple substance use requires tailored interventions with consideration to context of their use. Discussion includes limitations to generalizability and assessment of substance use as well as implications for treatment and future research.     

Outcomes for women with co-occurring disorders and trauma: program and person-level effects

Six-month outcomes are evaluated from a 9-site quasi-experimental study of women with mental health and substance use disorders who have experienced physical or sexual abuse who enrolled in either comprehensive, integrated, trauma-informed, and consumer/survivor/recovering person-involved services (N = 1023) or usual care (N = 983). Mental health, post-traumatic stress symptoms, and substance use outcomes are assessed with multilevel regression models, controlling for program and personal characteristics. Person-level variables predict outcomes independent of intervention condition and, to a small extent, moderate intervention and program effects. In sites where the intervention condition provided more integrated counseling than the comparison condition, there are increased effects on mental health and substance use outcomes; these effects are partially mediated by person-level variables. These results encourage further research to identify the longer-term effects of integrated counseling for women with co-occurring disorders and trauma histories.     

FUNDING WATCH

ABSTRACT

Integrated Dual Diagnosis Treatment (Drake et al.), an Evidence-Based Practice designed for persons with co-occurring mental illness and substance use disorders, was developed for delivery in outpatient settings and has been implemented widely in community mental health centers. Until recently, inpatient services compatible with IDDT were not available for dually diagnosed individuals who experienced psychiatric hospitalization at the onset of illness or over the course of treatment. For those individuals receiving outpatient IDDT, hospitalization could mean a disruption to gains painstakingly achieved in the community. Historically, inpatient psychiatric treatment has not been integrated with treatment for substance use nor has it been delivered by staff with expertise in both disorders. An initiative spearheaded by the Ohio Department of Mental Health (ODMH) and the Ohio Substance Abuse and Mental Illness Coordinating Center of Excellence (SAMI CCOE) to transfer the demonstrated value and success of the original outpatient IDDT model to the inpatient setting began close to three years ago. Building on the experience of some pioneering Ohio inpatient SAMI programs (Hurst, Neuzil et al, in preparation), and the experience of the SAMI CCOE and ODMH, a collaborative workgroup developed an IDDT Inpatient Adaptation protocol and fidelity index that has since been piloted at a number of sites in Ohio's Integrated Behavioral Healthcare System (IBHS). A work in progress, the IDDT Inpatient Adaptation is an important step toward providing consistent and continuous care to persons with co-occurring disorders across service delivery settings.     

A Randomized Controlled Trial Comparing Integrated Cognitive Behavioral Therapy Versus Individual Addiction Counseling for Co-occurring Substance Use and Posttraumatic Stress Disorders

OBJECTIVE: Co-occurring posttraumatic stress (PTSD) and substance use disorders provide clinical challenges to addiction treatment providers. Interventions are needed that are effective, well-tolerated by patients, and capable of being delivered by typical clinicians in community settings. This is a randomized controlled trial of integrated cognitive behavioral therapy for co-occurring PTSD and substance use disorders. METHODS: Fifty-three participants sampled from seven community addiction treatment programs were randomized to integrated cognitive behavioral therapy plus standard care or individual addiction counseling plus standard care. Fourteen community therapists employed by these programs delivered both manual-guided therapies. Primary outcomes were PTSD symptoms, substance use symptoms and therapy retention. Participants were assessed at baseline, 3- and 6-month follow-up. RESULTS: Integrated cognitive behavioral therapy was more effective than individual addiction counseling in reducing PTSD re-experiencing symptoms and PTSD diagnosis. Individual addiction counseling was comparably effective to integrated cognitive behavioral therapy in substance use outcomes and on other measures of psychiatric symptom severity. Participants assigned to individual addiction counseling with severe PTSD were less likely to initiate and engage in the therapy than those assigned to integrated cognitive behavioral therapy. In general, participants with severe PTSD were more likely to benefit from integrated cognitive behavioral therapy. CONCLUSIONS: The findings support the promise of efficacy of integrated cognitive behavioral therapy in improving outcomes for persons in addiction treatment with PTSD. Community counselors delivered both interventions with satisfactory adherence and competence. Despite several limitations to this research, a larger randomized controlled trial of integrated cognitive behavioral therapy appears warranted.     

Treating adolescents for substance abuse and comorbid psychiatric disorders

Recent research has identified a cluster of standardized approaches that effectively treat adolescents with substance abuse disorders. Many of these approaches share elements that may be adopted to improve outcomes in substance treatment programs. In adolescents, treatment goals should be informed by a comprehensive assessment that includes the adolescent patient's developmental history and evaluation of psychiatric comorbidity. Treatment for behavioral, psychosocial, and psychiatric problems should be integrated with substance abuse interventions. The author describes practical clinical guidelines, grounded in current research, for providing integrated treatment services. Special emphasis is given to strategies for integrating the treatment of comorbid psychiatric disorders with substance use disorders in adolescents.     

Understanding clinical complexity in delinquent youth: comorbidities, service utilization, cost, and outcomes

This study describes the extent and severity of multiple comorbidities in ajuvenile detention center population, and explores how these numerous problems impact the utilization of treatment services, costs, and outcomes including those for substance abuse, mental illness, and criminal activity. Cluster analyses of the outcome scales at intake yielded two groups: youth high (42%) and youth lower (58%) on all factors. Girls experienced the most significant impairments across emotional problems, behavior complexity, internal mental distress, and victimization domains, utilized significantly more units of residential treatment,individual counseling and case management, and had the highest treatment costs. The total cost of services ($1,171,290, N = 114) was significantly related to substance problems in the past year (r = .219, p < .05), emotional problems (r = .237, p < .05), behavior complexity (r = .318, p < .05), internal mental distress (r = .263, p < .05), environmental risk (r = .205, p < .05), and conflict tactics (r = .240, p < .05). Despite initial differences in measures of baseline severity, high and low cluster youth, and boys and girls in general, achieved similar results on the key outcome variables 12 months later. Study implications include a need for co-occurring, integrated treatment efforts that address family, emotional, and mental health problems of delinquent youth (especially females) in order to improve their ability to successfully attend to substance abuse problems and interpersonal conflicts.     

Drug treatment services for adult offenders: the state of the state

We conducted a national survey of prisons, jails, and community correctional agencies to estimate the prevalence of entry into and accessibility of correctional programs and drug treatment services for adult offenders. Substance abuse education and awareness is the most prevalent form of service provided, being offered in 74% of prisons, 61% of jails, and 53% of community correctional agencies; at the same time, remedial education is the most frequently available correctional program in prisons (89%) and jails (59.5%), whereas sex offender therapy (57.2%) and intensive supervision (41.9%) dominate in community correctional programs. Most substance abuse services provided to offenders are offered through correctional programs such as intensive supervision, day reporting, vocational education, and work release, among others. Although agencies report a high frequency of providing substance abuse services, the prevalence rates are misleading because less than a quarter of the offenders in prisons and jails and less than 10% of those in community correctional agencies have daily access to these services through correctional agencies; in addition, these are predominantly drug treatment services that offer few clinical services. Given that drug-involved offenders are likely to have dependence rates that are four times greater than those among the general public, the drug treatment services and correctional programs available to offenders do not appear to be appropriate for the needs of this population. The National Criminal Justice Treatment Practices survey provides a better understanding of the distribution of services and programs across prisons, jails, and community correctional agencies and allows researchers and policymakers to understand some of the gaps in services and programs that may negatively affect recidivism reduction efforts.     

Therapeutic community treatment for substance abusers with antisocial personality disorder.

This study compared treatment outcomes of substance abusers with and without antisocial personality disorder (APD) randomly assigned to two therapeutic communities, differing primarily in length of inpatient and outpatient treatment. We hypothesized that APD clients would be less likely to complete treatment, more likely to test positive for drugs and recidivate at follow-up, and that APD clients in the Standard program would have more favorable outcomes than those in the Abbreviated Inpatient program, because of the Standard program's longer inpatient treatment. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. APD clients were as likely to complete treatment as other clients, and they exhibited the same patterns of reduced drug use and recidivism as did non-APD clients. Treatment program attended was unrelated to outcomes. Substance abusers diagnosed with APD can benefit from treatment in a therapeutic community combined with outpatient care.     

Integrated Mental Health/Substance Abuse Responses to Justice Involved Persons with Co-Occurring Disorders

ABSTRACT

There is an overrepresentation of persons with co-occurring disorders (COD) involved in the criminal justice system. The provision of integrated services to persons with COD has been identified as an evidence-based practice (EBP), and data suggests that positive public safety and health outcomes for justice involved persons with COD are associated with integrated program models as well. Sadly, in real world settings the vast majority of persons with COD, including those with histories of justice involvement, do not have access to integrated care. This paper will review the research associated with integrated treatment, highlight efforts to adapt integrated treatment for justice involved persons with COD, and describe efforts along a justice continuum to identify and link these persons to integrated treatment.