Effective Intervention Strategies for Offenders with Co-Occurring Mental and Substance Use Disorders

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1 Effective Intervention Strategies for Offenders with Co-Occurring Mental and Substance Use Disorders Utah Fall Substance Abuse Conference Act, St. George, Utah September 24, 2014 Roger H. Peters, Ph.D., University of South Florida

2 Goals of this Presentation Review: Evidence-based interventions for offenders who have co-occurring disorders Effective models of COD treatment Adaptations to offender treatment and supervision

3 Resources SAMHSA s GAINS Center CSAT TIP #42 and # / Council of State Governments - Justice Center

4 Resources SAMHSA/CMHS Toolkit on Integrated Treatment for Co-Occurring Disorders -Treatment-for-Co-Occurring-Disorders- Evidence-Based-Practices-EBP- KIT/SMA

5 Prevalence of Mental Illness in Jails and Prisons Serious Mental Disorders among Offenders and the General Population Percentage of Population Sources: General Population (Kessler et al.,1996), Jail (Steadman et al., 2009), Prison (Ditton 1999)

6 Co-Occurring Substance Use Disorders 74% of state prisoners with mental problems also have substance abuse or dependence problems Source: U.S. Department of Justice, 2006

7 Persons with CODs Repeatedly cycle through the criminal justice and treatment systems Experience problems when not taking medications, not in treatment, experiencing mental health symptoms, using alcohol or drugs Small amounts of alcohol or drugs may trigger recurrence of mental health symptoms Poor outcomes in traditional treatment programs

8 Treatment History among Arrestees in ADAM Study ( ; n = 18,421)

9 Severity of Substance Use and Treatment History No Treatment Mental Health Treatment Substance Use Treatment Substance Use & Mental Health Treatment M (SD) M (SD) M (SD) M (SD) F (df) Drug Use Severity Alcohol Use Severity 2.6 (1.9) 3.1 (2.0) 3.7 (2.1) 4.2 (1.9) (3)*** 2.3 (2.0) 3.2 (2.0) 3.5 (2.1) 3.9 (2.0) (3)*** *** p <.001

10 For Persons with Mental Illness, only 8% of Arrests are Attributable to Mental Illness Junginger, Claypoole, Laygo, & Cristina (2006); National Reentry Resource Center

11 Offenders with Mental Illness have Higher Levels of Criminogenic Risk Key Criminogenic Risks ** Antisocial attitudes and beliefs Antisocial peers Antisocial personality features Substance use disorders Family/marital problems Lack of education Poor employment history Few prosocial/leisure skills Skeem, Nicholson, & Kregg (2008), National Reentry Resource Center, 2012

12 Implications for Offender Treatment Mental Disorders and Criminal Behavior Target CODs in offender treatment programs that have resources to address high risk and high need participants For participants with CODs, treating mental disorders is insufficient to reduce recidivism However, mental health services enhance participants responsivity to evidence-based treatments that address key criminogenic risk areas (substance abuse, criminal beliefs/attitudes, criminal peers, education, employment, family discord, leisure skills) Therefore, offender treatment and supervision should address both CODs and other areas of criminogenic risk

13 Screening and Assessment of CODs Don t exclude persons based on serious mental illness, severity of substance use problems, or active substance use Screening Blended and routine screening for MH, SA, and trauma/ptsd Identify acute symptoms Focus on areas of functional impairment that would prevent effective program participation Assessment Examine longitudinal interaction of disorders Review participant motivation over time Periodic reassessment Peters, 2014; Council of State Governments Justice Center

14 2014 Monograph: Screening and Assessment of Co-Occurring Disorders in the Justice System

15 Evidence-Based Models to Guide COD Treatment Integrated Dual Diagnosis Treatment (IDDT) Risk-Need-Responsivity (RNR) Model Cognitive-Behavioral Treatment (CBT) Social Learning Model Combining several models produces larger reductions in recidivism (26-30%; Dowden & Andrews, 2004)

16 Common Features of CBT and Social Learning Models Focus on skill-building (e.g., coping strategies) Use of role play, modeling, feedback Repetition of material, rehearsal of skills Behavior modification Interpersonal problem-solving Cognitive strategies used to address criminal thinking

17 Risk-Needs-Responsivity (RNR) Model Focus resources on high RISK cases Target criminogenic NEEDS: antisocial behavior, substance abuse, antisocial attitudes, and criminogenic peers RESPONSIVITY Tailor the intervention to the learning style, motivation, culture, demographics, and abilities of the offender. Address issues that affect responsivity (e.g. mental illnesses).

18 18

19 Evidence-Based Treatment Interventions for Offenders Integrated MH and SA treatment Cognitive-behavioral treatments Relapse prevention Motivational interventions (MI/MET) Contingency management Behavioral skills training Medications (for both disorders) Trauma-focused treatment Family interventions (psychoeducational)

20 COD Treatment Curricula Integrated Treatment for CODs Illness Management and Recovery (IMR) Integrated Group Therapy for Bipolar Disorder and Substance Abuse Substance Abuse and Trauma/PTSD Integrated Cognitive Behavioral Therapy Seeking Safety

21 Adaptations for CODs Highly structured treatment services Destigmatize mental illness Focus on symptom management vs. cure Education regarding individual diagnoses and interactive effects of CODs Criminal thinking groups Basic life management and problem-solving skills

22 Adaptations for CODs Higher staff-to-participant ratio Dually credentialed staff Increased length of services - Pace of treatment slower - Flexible progression through treatment allowed - Ongoing tracking and case monitoring - Extended exit and re-entry policies - Treatment may last for more than one year

23 Adaptations for CODs Greater emphasis on education and support rather than compliance and sanctions Motivational interventions in both group and individual settings Cognitive and memory enhancement strategies Focus on housing, employment, medication needs

24 Modifying Court Hearings More frequent court hearings may be needed Hearings provide a good opportunity to recognize and reward positive behavioral change Less formal, smaller, more private Greater interaction between judge and participants Include mental health professionals

25 Modifying Community Supervision Specialized MH/COD caseloads Smaller caseloads and more intensive services Dual focus on treatment and surveillance Active engagement in SA and MH services Problem-solving approach vs. reliance on sanctions Flexibly apply sanctions Higher revocation threshold Ongoing and specialized officer training Improved outcomes (Skeem et al., 2009)

26 Prison Treatment and Reentry % MH 16% TC only TC + aftercare 5% 0 Total n=139 n=64 n=32 n=43 Sacks et al. 2004

27 Summary of Key Points Significant proportion of offenders have CODS Multiple challenges, but important target population Features of evidence-based COD treatment: - Integrated and multi-component (MH, SA, crim.) - Curriculum-based Adaptations for offender COD treatment Modify approaches used in court hearings and community supervision

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