Amherst Drug Treatment Court

Transcription

1 Amherst Drug Treatment Court Co-Occurring Disorders Treatment Track: Genesis, Creation, and Evaluation Consultants: Richard Washousky David Washousky Shari Greenwood November 2011 This study was developed under grant number 2009-DC-BX-0039 from the United States Department of Justice, Office of Justice Programs. The points of view expressed are those of the authors and do not necessarily represent the official position or views of the Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice, the Town of Amherst, or the Amherst Drug Treatment Court. 1

2 Table of Contents I. Acknowledgements 4 II. Executive Summary 5 Key Findings 6 Key Recommendations 7 III. Introduction to Co-Occurring Disorders 9 IV. Introduction to the Amherst Drug Treatment Court (ADTC) 12 V. Amherst Co-Occurring Track: Genesis, Need, and Implementation 13 VI. Research Methodology 15 Process Gap Analysis Intake procedures Data entry in Management Information System (MIS) Administering Mini-International Neuropsychiatric Interview (MINI) and Quality of Life (QLI) 20 Creation of a separate Co-Occurring Disorder Track (COD) 21 Adding ancillary services 22 VI. Qualitative and Quantitative Findings 22 Court Observations Results 22 Strengths 23 Challenges 24 Opportunities 25 Threats 25 Court Observations Summary 26 Participant Interviews 27 Quantitative Results of Participants in Transfer and Amherst Co-occurring Group Age range Gender Ethnicity Education level (self-reported) Primary drug of choice Past history of treatment Primary mental health diagnosis Outcome disposition at the time of grant completion 36 Amherst, Lackawanna, and Buffalo Co-occurring treatment courts Age range 38 2

3 1.10 Gender Ethnicity Education level (self-reported) Age of first use Primary drug of choice Primary mental health diagnosis 44 Inferential observations of Amherst, Lackawanna, and Buffalo 45 Amherst Court Grant Participants MINI and QLI Results 46 Transfer Group 46 Co-Occurring Track 46 VII. ADTC Goal Completion 47 VIII. Procedural Recommendations 50 Intake 50 Database Collection and Analysis 51 Creation of a Separate Co-occurring Disorders Treatment Track 52 Adding ancillary services 53 IX. Direction for Future Research and Enhancement 54 X. Works Cited 55 XI. Appendices Appendix A: Recovery Solutions Decision Making Matrix 58 Appendix B: Recovery Solutions Data Tracking Matrix 59 3

4 Acknowledgements The staff of Recovery Solutions would like to thank the following individuals for their help and cooperation in conducting this evaluation. Amherst Drug Treatment Court Staff Honorable Mark Farrell Presiding Judge, ADTC James Loughran Court Administrator James Cavanaugh Therapeutic Courts Coordinator Eileen Logsdon Therapeutic Courts Director/Court Analyst Carrie Frigon Horizon Health Services Case Manager 8 th Judicial District Staff/Unified Court System Honorable Paula L. Feroleto Administrative Judge Jeff Smith Projects Director Ann Bader Robyn Cohen Michael Magnani Division of Grants and Program Development Division of Grants and Program Development Division of Grants and Program Development 4

5 Executive Summary It is indisputable that an increasing number of participants with co-occurring substance abuse and mental health disorders are entering the criminal justice system (CJS) every year. According to the U.S. Department of Justice, approximately 74% of state prisoners and 76% of local jail inmates who had a mental health problem also met criteria for substance dependence or abuse (James, D. & Glaze L.: U.S. BJS, 2006). This trend poses a growing social problem that burdens both the criminal justice system and the public mental health system due to increasingly high costs of incarceration and the difficult nature of treating and rehabilitating this particular population. An increasing number of problem solving courts that simultaenously address co-morbid symptoms have been developed nationally to address this growing population. Co-occurring disorders courts create a seamless delivery system that treats symptomolgy of both substance abuse and mental health disorders. This delivery system fosters an environment that treats the root causes of a participant s issues with substance abuse, mental health, and their subsequent entanglement in the CJS. Recognigtion of the ability of co-occurring courts to more effectively handle co-morbid disorders has been evidenced by the development of grant funded co-occurring courts in Buffalo and Lackawanna. The Amherst Drug Treatment Court (ADTC) recognized the issue of comorbid disorders in their own court population in early This grant was written in response to the fact than an estimated 50% of ADTC terminations were thought to have co-occurring disorders. The primary focus of the grant was two-fold and involved the creation of a specific co-occurring disorders track in the ADTC, and the transfer of individuals identified as having severe persistent mental illness (SPMI) to mental health courts in Buffalo, Lackawanna, Niagara Falls, and Tonawanda. The stated goal of the project was to identify and service 120 individuals over the two year grant period. This goal was accomplished as measured by the 88 individuals placed in the cooccurring disorders track and the 51 indidviduals who were transferred from the ADTC to local mental health courts. However, during our evaluation it became clear through court observation, meetings with staff, and reviews of the quarterly reports that the ADTC staff was intially more focused on transfering individuals identified as SPMI to local mental health courts. The development of a specific co-occurring disorders track didn t occur until the second year of the grant period, and 5

6 was blended into the general ADTC drug court. This resulted in fewer specific ancillary services and less indvidual attention for this population, both of which are very important for this cohort. It would have been expected that this population would show higher failure rates in this environment, however at the time of grant completion 79% of co-occurring track participants were still active. This is a tremendous accomplishment for the ADTC given that co-occurring disorder cohorts tend to have higher rates of failure and is indicative of a successful court room environment in Amherst. Recovery Solution s grant evaluation was focused on providing qualitative and quantitative data to assess grant outcomes and make both process and treatment recommendations. Evaluation activities culminated in the creation of a decision tree matrix to assist court staff with early identification of potential mental health symptoms as well as a guide for referring clients to the most appropriate problem solving court. The following is a summary of both key findings and key recommendations. Key Findings Amherst Drug Treatment Court achieved their goal of identifying 120 participants with mental health issues in need of COD or mental health court services The ADTC was successful in creating a COD track within the framework of the drug court population, showing a high rate of retention for this particular population (79%) The ADTC began the process of implementing the MIS database system, identifying participants by demographic variables and allowing for tracking and monitoring, as well as the use of standardized mental health and quality of life instruments. However, complete data and use of evaluative instruments were not fully completed for grant participants. This may have significantly impacted the ability to identify and refer individuals with higher severity mental health sypmtomology into more specialized mental health court services. This also compromised the Evaluator s ability to determine the predictive variance for successful outcomes or failures. Having had this data would significantly improve treatment planning and court case management. Requisite training in identifying and treating co-occurring disorders for ADTC staff was completed There was some statistical difference between demographic and clinical variables from participants who were transferred to local mental health courts and participants who were 6

7 retained in the ADTC. This was apparent when analyzing mental health diagnoses for schizophrenia and bipolar illness between the two cohorts. However, depression diagnoses did not significantly differ between the two groups. This finding validates clinical research as well as previous Recovery Solutions evaluations dealing with severe and persistently mentally ill patients. Furthermore, those with co-occurring disorder symptoms appear to be able to be integrated into existing drug court programs. However, there is no current research to indicate the long term impact/outcomes for COD tracks that operate within the framework of drug courts. Longitudinal studies are needed to insure best practices. It is the opinion of Recovery Solutions that COD participants can be part of the drug court, but they should be seen in separate court sessions. Key Reccomendations The creation of a separate co-occurring disorders track Use of the newly created Recovery Solutions Decision Making Matrix to assist staff in the identification and correct placement of participants during the initial screening and intake. A software program could be written by Recovery Solutions to provide intake staff with a computerized decision making system with clear recommendations as to which court would likely best suit the participant s individual needs. Training in the use of this program could be provided by Recovery Solutions. Standardized intake proceudres that utlize the Mini-International Neuropsychiatric Interview (MINI) and Quality of Life surveys. Training staff in the correct use of these instruments, as well as the Access Data Base System is needed. Use of the newly created Recovery Solutions Data Tracking Matrix to track and monitor participants in the co-occurring disorders track. This court/clinical instrument can effectively monitor ongoing participant progress, provide variables to statistically predict the likelihood of successful outcomes, and provide an immediate change in treatment planning should the participant s substance or mental health issues change. Training is available from Recovery Solutions in using this tracking system. Expansion of ancillary services specifically geared for participants with co-occurring disorders to address the needs of participants as identified by the Quality of Life Inventory 7

8 The above recommendations are specific to the Amherst Evaluation to foster best practices in COD Judicial Case Management. However, this can become a national model for other COD & Mental Health Problem Solving Courts 8

9 Introduction to Co-Occurring Disorders The Center for Substance Abuse and Treatment (2005) defines co-occurring, or dual diagnosis as persons that have a substance abuse disorder and a concurrent axis I or axis II mental health diagnosis that exists independently of each other. Each illness has symptoms that interfere with a person s ability to function effectively and each/both may affect a person physically, socially, psychologically, and spiritually. The illnesses may affect each other, and each disorder predisposes individuals to relapse in the other disease(s). At times the symptoms can overlap and even mask each other, making diagnosis and treatment difficult. There were an estimated 45.1 million adults, age 18 or older in the United States, with some form of mental illness in 2009; 8.9 million of those adults also met the criteria for substance dependence or abuse (SAMSHA, 2009). It is indisputable that an increasing number of these individuals are entering the criminal justice system each year. According to the U.S. Department of Justice, approximately 74% of state prisoners and 76% of local jail inmates who had a mental health problem met criteria for substance dependence or abuse (James & Glaze, 2006). This trend poses a growing social problem that burdens both the criminal justice system and the public mental health system due to increasingly high costs of incarceration and the difficult nature of treating and rehabilitating this particular population. Due to the rise of individuals entering these two systems many have suggested that co-morbidity may be expected, rather than being a unique or atypical diagnosis. The co-occurrence of mental health and substance abuse disorders can have significant impacts on criminal justice services, health care delivery and costs, and on individual quality of life. Aharonovich, Liu, Nunes & Hasin, (2002) discuss higher relapse rates for substance users with a concurrent mental disorder, the increased likelihood that symptoms of mental illness will 9

10 return for those with a concurrent substance use problem, lower rates of completing treatment, shorter stays in treatment, and a higher risk of suicide. Individuals experiencing these disorders simultaneously also have particular difficulties seeking and receiving diagnostic and treatment services. Separately, these disorders may be linked to appropriate identified providers. However, this does not necessarily mean all disorders are being addressed effectively. To fully recover, a person needs treatment for both disorders simultaneously and with integrated services. In the past, providers may have focused on singular disorders with traditional treatment methods rather than treating the symptoms of each disturbance. Maisto & Kivlahan (2008) discuss the following as barriers to substance use disorder treatment facilities: lack of staff time, the accessibility of psychiatric expertise, and a lack of administrative support. One could infer that even if an individual is seeking treatment for a substance abuse and/or a mental health disorder, treatment providers are challenged to identify, assess, and successfully rehabilitate the individual if co-occurring disorders are present. Though the challenges associated with co-occurring disorders have long been acknowledged and discussed, there has been little consensus about how to accomplish needed system changes. It s challenging to conclusively determine how many people have a dual diagnosis because existing studies examine different populations and utilize different screening tools. Further, people with dual disorders are frequently misidentified, as diagnosis can be more difficult because one disorder can mimic another. The stigma associated with substance abuse disorders and mental disorders may also stand between many individuals with co-occurring disorders and successful treatment and recovery. The challenges of diagnosing and treating dual diagnosis are also compounded by the existence of two separate service systems, one for mental health services and another for 10

11 substance abuse treatment. Too often, when individuals with co-occurring disorders do enter specialty care, they are likely to bounce back and forth between the mental health and substance abuse service systems, receiving treatment for the co-occurring disorders episodically. It s not surprising that high rates of co-occurring substance abuse disorders and mental disorders are seen in criminal justice settings. Clearly, co-occurring substance related and mental disorders present significant challenges to both the local public health system, as well as criminal justice policy makers. The traditional approach to processing criminal cases often creates a barrier that prevents the court from identifying and responding to the unique needs of the chemically addicted offender with cooccurring psychiatric symptoms. Many people with co-occurring disorders are simply overlooked, turned away, or intimidated by the treatment system and end up disconnected from community support systems. The end result is predictable as many of these individuals find themselves recidivating back into the criminal justice system. Creating treatment courts that link the challenges of mental health and substance abuse into one seamless delivery system has been a positive step forward in addressing the difficulties associated with treating co-occurring disorders. However, this movement from punitive criminal courts to problem solving courts identified by disorder (drug, DUI, mental health, and cooccurring) has created new decision making challenges as to which participants are better served in which court. With over 60% of substance abusing participants having comorbid Axis 1 and Axis II diagnoses, this type of court participation requires clear decision matrices that provide guidelines for court and treatment professionals (Washousky, 2007). As discussed in the final report from the National Association of State Mental Health Program Directors (NASMHP) and the National Association of State Alcohol and Drug Abuse 11

12 Directors (NASADAD) Task Force on Co-occurring Disorders, a two by two matrix was developed to solve decision-making challenges. This matrix simultaneously looked at high and low levels of both substance abuse issues and mental health issues. The intent was to focus on severity of mental illness and substance abuse to define the four sub-groups of individuals with co-occurring disorder in order to divert each individual to the appropriate pathway of care. However, it failed to consider criminal history as a factor in the decision-making process. Additionally, it did not consider Axis II personality disorders clearly in the 2 x 2 matrix, which is an increasing population in problem solving courts today. Addressing the difficulty of diagnosing mental health and substance abuse severity and referring participants to the correct court is perhaps one of the greatest challenges facing problem-solving courts today. Introduction to The Amherst Drug Treatment Court (ADTC) The ADTC is one of seven drug courts in operation within Erie County. It is located 20 miles Northeast of the city of Buffalo and serves a total local population of 116,000, making it the largest town court in the state of New York. Created in September of 1996, the primary goal of the ADTC is to provide non-violent substance abusers with intervention consisting of treatment, education, case management, and judicial supervision. ADTC is both a pre-plea and post-conviction program. Participants in the ADTC are non-violent misdemeanants whose substance abuse or dependency appears to have significantly contributed to the current criminal case. The ultimate purpose of the ADTC is to successfully treat and rehabilitate the participant, and facilitate positive reintegration into the community, with success being defined by graduation from the program. 12

13 Amherst Co-Occurring Track: Genesis, Need, and Implementation In response to the increasing number of individuals perceived as having both substance abuse and mental health issues entering the Amherst Drug Treatment Court, the ADTC sought to implement a co-occurring disorders track (COD) within the existing drug court structure. Prior to the implementation of the grant it was estimated that over 50% of terminations from the ADTC had a co-occurring disorder. This track would provide additional access to mental health services and also track mental health treatment progress for this cohort. Key areas targeted by the ADTC for servicing the targeted population include the following: screening and assessments that examine both mental health and substance abuse, education and training for ADTC staff regarding concurrent mental health and substance abuse disorders, medication monitoring and drug testing, flexible application of graduated sanctions to accommodate the effects of mental disorders, individualized needs, and continuing consultation with community mental health and substance abuse treatment providers. All of the aforementioned enhancements were targeted with the goal of creating a continuum of care for individualized intensive case management. Evaluation of these goals and dissemination of findings to relevant community outlets were also priorities. To accomplish these goals, the ADTC proposed adding an intensive case management team for Drug Court participants assigned to the co-occurring track. Horizon Health Care was to be contracted for the development of this integrated team. The proposed team included one full time and one half-time healthcare professional who would be responsible for coordinating mental health services, including building improved linkages to existing community based mental health services, developing and monitoring appropriate Drug Court requirements, and serving as resource specialists for other members of the ADTC team. Standards and protocols were also to 13

14 be developed in order to refer a case for mental health screening and for specialized case management services. Theses enhancements to the ADTC were designed to provide a blended set of mental health and substance abuse services, including interventions, intensive treatment, relapse prevention, and improved life skills and transition. Other program enhancements included individualized mental health counseling, psychiatric consultation, intensive case management and outreach services, and the utilization of community supervision teams that embrace smaller case loads with staff who are trained in CODs. The ADTC co-occurring track had a goal to target non-violent offenders per year during the associated grant period. The case management team would coordinate social service needs, treatment and mental health service plans, vocational and educational services, health care, relapse prevention and placement for these individuals. Participants would be evaluated using a conceptual model that utilizes a two by two matrix rating severity of both their mental health and substance abuse problems. Individuals assessed as having a high severity of mental health problems and low severity of substance abuse problems were to be transferred to the Buffalo Mental Health Court, which is better designed to provide services for this population. Individuals assessed as having low severity of mental health problems and either concurrent low or high severity of substance abuse problems would be assigned to the COD track. Diagnoses were confirmed on all COD cases by the treatment providers retrospectively, separate from those cases determined to have severe mental health issues and/or needing more intensive court monitoring based upon treatment provider recommendations. These cases were linked to Buffalo, Lackawanna, Tonawanda and Niagara Falls Mental Health Courts. Also, a small group of 11 participants were engaged in services at the Buffalo Drug Court. 14

15 Research Methodology Recovery Solution s aim was to gather qualitative and quantitative outcomes in order to assess the success of creating a functional COD track in the ADTC. In order to do so, much of our time was spent assisting Amherst court staff with data entry into the Management Information Systems Access database developed by the Buffalo Drug Court staff (2001) and administering Mini International Neuropsychiatric Interviews (MINI) and Quality of Life Interviews (QLI). These interviews were completed face to face with participants and were used in diagnosing mental health symptoms, as well as exposing thematic areas of concern in the quality of life of court participants. Erie Community College staff interviewed an estimated 200 participants during the second year of the grant to assist with data collection and input. The majority of first year participants, however, did not have completed intakes, MINIs and QLI inventories. This undertaking was difficult to complete because many of these participants were already transferred to other courts, terminated or were out on warrant. This resulted in incomplete participant data making statistical analysis difficult and requiring more inferential conclusions and recommendations. These issues are highlighted further in the GAP Analysis section of this evaluation and are addressed in the recommendations. A total of four court observations were also completed (2/2010, 3/2010, 2/2011, 6/2011) during the grant period in order to evaluate the strengths, challenges, opportunities, and threats (SCOT Analysis) of the Amherst Drug Treatment Court. Two SCOT reports were provided to court staff to validate positive outcomes and address any weaknesses or threats to the success of the court. 15

16 Approximately five (5) meetings were held with ADTC stakeholders during the grant period in order to clarify grant expectations. These meetings included members of the Recovery Solutions team, as well as the Honorable Judge Mark Farrell (not at each meeting), James Lougrhan, Court Administrator, James Cavanaugh, Eileen Logsdon, and the ADTC COD Track Case Manager Carrie Frigon. These meeting were to get an update on the data collection using the MIS system and the participant screening instruments. It was noted during the initial meetings that the data was not consistently being gathered and the staff were having some difficulty using the software system despite initial training sessions on the navigation of the MIS system. The number of court participants in drug, co-occurring, gambling, compliance and veterans made the task too enormous for the staff resources. The existing Amherst Court database-monitoring program indicated there were 98 participants active on September 1, 2009 at the start of the grant. The ADTC admitted 200 individuals in year 1 and 269 in year 2 of the grant for a total of 567 participants. It was an ambitious attempt to create data sets and analysis on all these participants and then create separate data sets for each participant cohort, but it was unrealistic. This was especially challenging as the first year of the grant was more focused on providing case management services to the group identified as having severe mental health and substance disorders and needing linkage with mental health court treatment providers. In order to assist with these issues, Erie Community College received an Oishei Grant to add more staff to the Education 2 Recovery Program for expansion of problem solving courts. Given these added resources in February 2011, the Assistant Project Director was assigned to the Amherst Court on Tuesdays each week to screen participants for enrollment in academic services at the college and help with database collection. This person conducted over 200 interviews 16

17 during weekly scheduled court appearances, giving information to participants about the Education 2 Recovery services at ECC while also completing MINI and QLI inventories. This resulted in 15 individuals enrolling in the E2R Program at college, with many indicating they wanted to wait and focus more on their immediate recovery issues. It was noted that many of the Amherst Court participants had college degrees or taken college courses. Others identified transportation limitations as reasons for their inability to enroll in the E2R Program. This information is further outlined in Figure 1.3 on the self-reported education level of participants in the Amherst Co-occurring and Transfer Cohorts. A significant volume of quantitative data was gathered for all participants entering the COD track and was differentiated with data from participants that were transferred out of the ADTC to other court programs. These variables included age, gender, race, mental health diagnosis, drug of choice, educational level, age of first arrest, number of rearrests in the last 24 months, age of first substance use, history of chemical dependency, and history of prior treatment for mental health or substance abuse. Additionally, these participants were administered the MINI tool and QLI interview tool. Of the 567 participants enrolled from September 1, 2009 through August 31, 2011, 139 participants were screened and identified as a candidate for either co-occurring court (88) or transfer (51) to surrounding mental health courts. The grant objective was to screen 120 individuals during the two-year grant period. This was exceeded by approximately 16%. Of the fifty-one (51) participants identified for transfer to more intensive mental health court services, 33 were linked to Buffalo, 5 to Tonawanda, 1 to Lackawanna and 1 to Niagara Falls. Eleven (11) of these cases were diagnosed with primary substance related disorders and connected to the Buffalo Drug Court (BFDC). The Amherst Court case manager indicated that transfers to BFDC 17

18 were made based on the convenience of location, as well as some participants having past experience with the BFDC. Interviews were completed on a small sample of 10 participants who were transferred from the ADTC to the Buffalo Mental Health Court as to their feelings, comments, and recommendations on the services provided by both courts. We did not interview the Amherst COD track participants because they were not identified by diagnosis until the last month of the evaluation period. It would be suggested that a sample of these COD participants be provided the same satisfaction survey and interview protocol as completed with the transfers cohort. Amherst Court Staff, an outside evaluator, or students in a Masters or Doctoral research methods course could administer the interviews. Participant information is essential for continuous assessment as well as planning and resource allocation. Quarterly reports submitted to the Bureau of Justice Assistance by the Amherst Court staff were also reviewed by Recovery Solutions staff and used to provide recommendations throughout the grant period. Process GAP Analysis A GAP analysis allowed us to chronologically examine the process of creating a functional pathway through the COD track. In doing so, gaps in the strength of the process were revealed. 1. Intake Procedure Initial intake procedures are essential to early identification and proper placement of participants into the correct treatment track. This is especially important for participants experiencing symptoms of both mental health and substance abuse disorders because they are particularly vulnerable to failure without early intervention. Unfortunately, co-occurring mental 18

19 health and substance disorders can be challenging to identify and diagnosis, making proper intake procedure vital to the success of creating a COD track. The grant narrative called for the development of standards and protocols for referring a case for mental health screening and specialized case management services. During meetings with the COD team it was found that mental health diagnoses were being determined by selfreports from the participants. However, confirmation of diagnosis was not being received from the treatment provider after referral. Confirmation was ultimately accomplished, albeit retroactively, by ADTC staff at the recommendation of Recovery Solutions. Communication between the court team and treatment provider is essential to providing a seamless delivery of specialized services, and is particularly important to the intake process. This confirmation establishes a baseline for referral into the COD track. It also would aid the ADTC in making decisions related to the transfer of participants to more specialized mental health courts. 2. Data entry in MIS The MIS database was built for Microsoft Access in order to gather and monitor participant data. This database was modified and installed in the ADTC to allow for tracking, monitoring, and evaluating COD track participants. Each new participant was to be entered into the database so that quantitative variables could be examined and thematic indicators of success and failure could be evaluated. Additionally, this would provide ADTC staff with timely access to participant records and increase the efficiency of case management services. Unfortunately, computers at the ADTC were initially not able to run the MIS database program, and new units had to be ordered. This set data collection back and did not allow for any preliminary data analysis. However, the ADTC staff was eventually able to backlog all of the participant information and is currently inputting new participants into the MIS. 19

20 3. Administering MINI s and QLI s The Mini International Neuropsychiatric Interview (MINI) is a short, structured diagnostic interview tool for psychiatric evaluation. It was installed in the ADTC for use as an evaluative tool to help staff make decisions related to the perceived severity of mental illness. This is especially important given that the grant called for using a two by two matrix of mental health and substance abuse severity as described in the introduction. It also provided important evaluation information such as data related to a history of abuse or trauma. During the early stages of year two it was apparent that computer setbacks and a huge volume of ADTC participants had created a large backlog of participants without completed MINI interviews. Staff from Recovery Solutions as well as Erie Community College helped administer roughly 200 interviews during the second year of the grant period. The completion of a MINI can provide critical data and should be included in the intake standards and protocols as an early intervention tool. Quality of Life (QLI) surveys were also to be administered to participants. This survey is intended to capture information related to specific areas of life where participants may be struggling. Completion of these surveys exposes trends in specific life areas that can then be addressed by the court. Examples include difficulty with transportation, money, employment, family relations, and housing. This information allows staff to target specific areas for an enhancement of services. However due to computer issues and high volume QLI surveys were backlogged so Recovery Solutions and Erie Community College staff assisted with the administering of the survey. Again, the completion of a QLI can provide staff with critical data to increase the effectiveness of court programming and should be included in standards in protocols. These 20

21 surveys should be administered on an annual or semi-annual basis as participants navigate both the treatment and judicial process. 4. Creation of a separate COD track One of the primary objectives of this grant was to increase the likelihood of successful rehabilitation for ADTC participants with demonstrable co-occurring disorders. To accomplish this, the ADTC was to develop a co-occurring track to improve case management, treatment opportunities, and support services. Throughout the evaluation process it was unclear whether participants in the ADTC were being identified as having a COD, and whether or not they were receiving separate services from the general drug court population. As described above, initial data entry was completed rather late in the process, making it difficult as evaluators to identify a separate COD cohort. However, court observations and meetings with court staff seemed to indicate that a separate COD track had not been created. This was confirmed when a COD team member stated that although COD participants had started to be identified late in the second year of the grant, they were not receiving any specialized services. Dual diagnosis participants benefit from intensified court management and linkages to Mentally Ill Chemically Abusers (MICA) specific services. As part of a large, homogenized population in the ADTC, these participants lack specific attention. In our experience, this group tends to have much higher failure rates to begin with, and without specific court attention failure rates will likely be higher. Identification is key, but the intensification of services is what truly increases the likelihood of successful rehabilitation. 5. Adding ancillary services A key component of a successful COD track is the addition of ancillary service providers 21

22 with specific COD experience in order to provide a comprehensive system that diminishes the duplication of services. These services should be specifically focused on intervention, intensive treatment, relapse prevention, and improved life functioning and transition skills. Examples of ancillary services include support groups, housing services, education services, halfway houses, community case managers, residential programs, job training, and volunteer services. There was progress made in the ADTC in terms of adding services, with specific examples including educational and vocational training through the Education 2 Recovery program, and the SCRAM program. However, there was a lack of targeted service providers added specifically for COD track participants. Seeking out these service providers and signing memorandums of understanding will increase the support network necessary to increase the likelihood of success among COD track participants. Qualitative and Quantitative Findings Court Observations Results Court observations were completed quarterly throughout the grant period in order to define the strengths, challenges, opportunities, and threats (SCOT) in the ADTC. The following SCOT analysis is a compilation of observations completed by Recovery Solutions staff and provides a basis for later process recommendations. Strengths A tremendous volume of offenders are being seen in each court session providing a service to the community and an alternative to incarceration During pre-court time in the hallway participants were with family members and seemed to be using similar experiences to form bonds 22

23 Court Coordinator is frequently approached and does well with giving appropriate time to individuals and recognizing those needing the most attention ADTC handles a diverse group of offenders with multiple alcohol, drug, and social problems ADTC is the largest town court in the state of New York Recognition of the honorable Judge Mark Farrell as a national leader in problem solving court jurisdiction Firm but fair treatment from Judge Farrell and the court team, employing human qualities like humor and offering their support to participants Pre-court case conferencing between ADTC staff and Judge Farrell was observed for a number of cases A higher ratio of participants appear to be employed or attending school compared to other problem solving courts Every participant attends an orientation session, a very positive approach that is not universally practiced. Includes contracts for enrollment, compliance, rules, sanctions and suboxone prescription no surprises, fosters participant responsibility and self monitoring of progress and when therapeutic interventions/sanctions are imposed by the Judge they are not perceived as punitive, but rather fair and expected Judge recognized participant s success in front of the group There is a strong Court Team from multiple treatment facilities with many years of clinical experience Judge is very knowledgeable of addictions, recovery, diagnoses and is firm, but fair in dispensing legal justice 23

24 Staff uses an integrative approach to handle individuals with gambling, substance abuse, and mental health disorders which helps create comprehensive treatment and focuses on increased functionality. Judge is willing to take cases that also are in other problem solving courts; realizing the importance of centralizing care and accountability Judge teaches honesty and integrity, necessary skills for recovery Cases are in the court for an average of months, however there are others with 2, 3 4 and 5 years attendance the team doesn t give up on individuals Challenges Lengthy waiting period before seeing judge due to high volume It seemed that many of the mental health cases weren t seen until the end of a long court session. This presents a focus challenge for some participants. Participants with good reports are limited in their access to the judge due to high volume It was observed individuals with mental health issues needing evaluation and linkage to more extensive monitoring services Case information on demographic, legal, and treatment history only existed in paper copy making monitoring and tracking difficult Unable to determine consistency in follow-up with treatment services, compliance, and resolution Time does not allow participants to tell much of their story, successful or unsuccessful Opportunities Possible linkage to Education 2 Recovery for vocational and educational training Utilization of the M.I.N.I. to assess mental health issues and possibly divert individuals 24

25 into the Buffalo Mental Health Court, reducing volume and increasing efficiency. Possible utilization of interns from University at Buffalo, Erie Community College, Hilbert and Medaille Colleges to assist with in-take screening and data collection The development of a group of successful alumni to provide a peers helping peers support program Possible digitization of paper copies to reduce volume and increase efficiency Threats Volume of offenders may be exceeding capacity Some offenders were observed indicating that they were also involved in problem solving courts outside of the ADTC, however its unclear if communication between these other courts is occurring Volume may be too high to adequately pre-conference all problem cases before court begins to assist with his decision making There is a lack of clarity and at times it seems like the Judge may not be presented with needed information on participant s treatment services and necessary linkages Court Observations Summary The ADTC is the largest town court in the state of New York and handles a tremendous volume of cases during each court session. The ability to manage such a high caseload was impressive to observe and should be commended. Several strengths were noted during the observation sessions. Judge Farrell is honest and strong from the bench providing a tough, but fair approach that teaches integrity and accountability. Similarly, it s clearly apparent that the ADTC staff is both knowledgeable and dedicated to working with each individual participant. Other notable achievements include a comprehensive orientation process, which we have 25

26 recommended to several other courts. Although the high volume of the ADTC is noted as a positive strength in its service to the community, it also presents some challenges. These challenges are particularly significant to treating individuals who have been diagnosed with co-occurring disorders. Individuals with COD may not be able to handle larger, more chaotic environments. They also may not receive the intensification of services necessary to treat both diagnoses because they get caught up in the flood of participants that see the judge during each court session. Time simply does not permit the judge and ADTC staff to give personalized attention and intensified management to every individual. We strongly recommend inclusion of individuals with a COD be seen in a separate session. It should be noted that ADTC staff addressed some of the challenges that were listed in the initial SCOT, including the utilization of the MINI. We recommend that ADTC staff continue to utilize this diagnostic tool in order to better identify participants with possible mental health issues. This will allow the court to identify participants early in the process and link them to the recommended treatment track. The digitization of paper records will help increase efficiency and allow the Judge and staff to better track and monitor individuals as they move through the court process. This will help to ensure that the staff has timely access to necessary information in the courtroom as well as reduce paper clutter. The ADTC staff has already included the Education 2 Recovery Program in their court process as noted in the opportunities section. This program has been successful in providing vocational and educational support to 15 participants since becoming active in the court in January

27 Participant Interviews Interviews were completed with 10 participants that had completed the transfer process from Amherst to the Buffalo Mental Health Court as to their feelings, comments, and recommendations on the services provided by both courts. All of the participants interviewed indicated that the change from Amherst to Buffalo was good for their recovery. Participants cited more mental health awareness and support services as the primary reasons for their increased success. Others indicated that their interaction with the judge was more positive in Buffalo. Although not explicitly stated by participants, it was inferred that the smaller court size was also beneficial. Participants were asked about their perception of the judge, treatment staff, and court structure in both Amherst and Buffalo. Over half of the participants reported that they felt the judge in Amherst was not personally concerned about them. Additionally, 40 % of the participants felt that visits with the judge in Amherst did not help them stay drug free. In our opinion, it s likely that the tremendous volume of participants in the ADTC made it difficult for Judge Farrell to give directed and personal attention to clients with mental health conditions. Transferring these clients to Buffalo where more specialized services and attention are available seems to have been the correct decision for these particular cases. Responses in regards to the Buffalo Mental Health Court showed that the majority of the participants reported that visits with the judge in Buffalo helped them to stay drug free. Additionally, the majority of the clients felt that the judge was concerned about their welfare and treated them with respect. This further supports the idea that this population may do better in smaller, more personalized court environments. 27

28 Quantitative results of Participants in Transfer and Amherst Co-Occurring Group The following charts depict demographic variables gathered for both the Amherst Co- Occurring track participants and the transfer group participants. Inferential comparisons were made between these two groups, as indicated in the following figures. 28

29 Age range of participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! %-./! 0*1233+##4%5!)#*+,! %-66! '#$ '(#$!)#$!"#$!(*')$$ '!*%)$ '&#$!%#$!"#$!(*')$ '!*%)$!&#$ %!#$ %!*&)$ &!*+)$ &%#$ %!*&)$ &!*+)$ +!*,)$ +!*,)$ Figure 1.1! In looking at the age ranges for the Amherst Co-Occurring group and transfer group it appears that the largest age range of participants for both groups was years old. When combining the age groups of 30 years old and under, the total percentage of participants was 49% of the transfer group and 61% for the co-occurring group. Both the transfer group and co-occurring group are clearly younger in age, and it s likely that both groups had interactions with the criminal justice system at an early age, however this could not be confirmed from the MIS ACCESS database information. 29

30 Gender of participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! 0*1233+##4%5!)#*+,! '-#$ (!#$./01$ &"#$ 213/01$ +'#$./01$ 213/01$! Figure % of the transfer group was male as compared to only 52% of participants in the Amherst Co-Occurring group. 48% of the COD group was female and continued research comparing gender and mental health diagnosis would be strongly suggested. 30

31 Ethnicity of participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! &#$ 0*1233+##4%5!)#*+,! +#$!#$,#$ -#$ '-#$ 45678/9$431678/9$ 45678/9$431678/9$ :/;8/<7/9$ :/;8/<7/9$ =7<>/978$ Figure 1.3 The transfer group had significantly higher proportions of minority participants (40%) when compared to the co-occurring group (15%). This may be due in part to the demographic profile of the Amherst Town Court. Also, the larger percentage of minorities in the transfer group could be related to where the participants reside, as Buffalo City Court may be closer to their residence. 31

32 Self-reported education level of participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! 0*1233+##4%5!"#$37!!)#$ ''#$!"#$ '(#$ '%#$ =7CA<8ADD0EFGH$ ID31$:D001C1$ :D001C1$!+#$ '&#$!-#$ %!#$!!#$ =7CA$I8ADD0EFGH$ ID31$:D001C1$ :D001C1$H1C611$ J9K9DL9$ J9K9DL9$ Figure 1.4 The transfer group had a large number of participants reporting less than a high school education at 27% versus 19% of the co-occurring track. The co-occurring group reported the largest number of participants with some college at 31% versus the transfer group at 22%. Additionally, 15% of the co-occurring track reported having a college degree versus 10% of the transfer group. 32

33 Primary drug of choice of participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! 0*1233+##4%5!"#$37! %#$ ')#$!'#$ ')#$ '#$ 408DAD0$ M19NDO7/N/>791<$ '"#$ %&#$ 408DAD0$ M19NDO7/N/>791<$ '%#$ '%#$ J9K9DL9$!,#$!,#$ %#$ J9K9DL9$! Figure 1.5 The transfer group s primary drugs of choice were crack/cocaine and marijuana, both at 23%. The next highest drugs of choice for the transfer group were alcohol and opiates at 20% each. The primary drug of choice for the co-occurring group was alcohol with 34%. The next highest drug of choice for the co-occurring group was opiates at 28% followed by crack/cocaine and marijuana both with 16%. The transfer and cooccurring groups reported a small number of participants with a primary drug of choice of benzodiazepines, transfer group 2% and co-occurring group 3%. 33

34 Past history of treatment for participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! 0*1233+##4%5!)#*+,!!'#$ %+#$ '%#$ Q1<$!)#$ Q1<$ +%#$ RD$ J9K9DL9$,(#$ RD$ J9K9DL9$ Figure 1.6 The transfer group reported 35% with a history of mental health treatment along with 67% of the co-occurring group. Both groups reported a treatment history of unknown with 12% of the transfer group and 23% of the co-occurring group falling into this category. The data for those reporting a past history of treatment is not what would have been expected for this cohort. Previous research data has indicated that SPMI individuals often have more contact with mental health treatment services. This may be the result of errors in self-reported information. 34

35 Primary Mental Health Diagnosis for participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! 89:(#&;!0*1233+##4%5!"#$37! )#$ +#$!)#$ %&#$!)#$ )#$ &!#$ M7>D0/6$ H1>61<<7D9$ UVIH$ J9K9DL9$ (#$!#$ (#$ %(#$ '%#$ '+#$ M7>D0/6$ H1>61<<7D9$ UVIH$ Figure 1.7 *Participants that were transferred to the Buffalo Drug Court for convenience were excluded from the transfer diagnosis data The transfer group reported 41% with a diagnosis of bipolar disorder while the co-occurring group reported 25%. The transfer group also had more participants diagnosed with schizophrenia with 10% versus 1% of the co-occurring group. This difference was expected due to the severity of bipolar and schizophrenia illnesses. Depression statistics were very similar with 34% of the transfer group and 37% of the co-occurring group falling into this category. 35

36 Outcome disposition at the time of grant completion for participants in the transfer group and the Amherst Co-Occurring Group "#$%&'(#!)#*+,! 8<"0!0*1233+##4%5!"#$37! &#$ '#$!'#$ -#$ '(#$ +(#$ 2/701O$ (-#$ 2/701O$ Figure 1.8 For the transfer group, 39% of the participants were either warranted out or failed versus 13% of the co-occurring group. The high rate of warrants and failures in the transfer group is symptomatic of their more severe mental health disturbances. The co-occurring group also had an increased number of active cases with 79% versus 57% for the transfer group at the conclusion of the grant period. Additionally, the co-occurring group had more successful graduates than the transfer group. This is a positive indicator for the ADTC co-occurring group, particularly because Figure 1.7 showed that several COD participants did in fact have major depressive disorders. 36

37 Amherst, Lackawanna, and Buffalo Co-Occurring Treatment Courts Figures 1.9 through 1.15 provide comparative analyses for the three Western New York courts that have established grant funded co-occurring treatment courts. Recovery Solutions completed evaluations on the Lackawanna (Washousky & Washousky 2011) and Buffalo (Washousky, R. 2007) co-occurring treatment courts in 2011 and The following figures represent comparative data and inferential conclusions on participant demographic and clinical variables for all three Western New York co-occurring courts. 37

38 Comparison of age range for participants in the ADTC Co-Occurring Track with evaluations in Buffalo (2007) and Lackawanna (2011)!"#$"%"&&"'()*+##,--.&/'0-"#$' &123' &#$ 4,55"6)'()*+##,--.&/'0-"#$' &1783' *#$!"#$!"#$!"'()$!*#$ (!#$!"'()$!"#$ %%#$ (!'*)$ *!'%)$ %!'&)$ **#$ *)#$ (!'*)$ *!'%)$ %!'&)$ &!'+)$ &!'+)$ 9:;<-=>'()*+##,--.&/'0-"#$' &122' (#$!*#$!,#$ (%#$!"'()$ (!'*)$ %*#$ *!'%)$ %!'&)$ &!'+)$ Figure

39 Comparison of gender for participants in the ADTC Co-Occurring Track with evaluations in Buffalo (2007) and Lackawanna (2011)!"#$"%"&&"'()*+##,--.&/'0-"#$' -./0$ 102./0$ 4,55"6)'()*+##,--.&/'0-"#$' -./0$ 102./0$ ("#$ "*#$ %)#$ +)#$ 9:;<-=>'()*+##,--.&/'0-"#$' %,#$ &(#$ -./0$ 102./0$ '' Figure

40 Comparison of ethnicity for participants in the ADTC Co-Occurring Track with evaluations in Buffalo (2007) and Lackawanna (2011)!"#$"%"&&"'()*+##,--.&/' 4,55"6)'()*+##,--.&/'0-"#$' &#$!#$ %#$ )#$ $ $!!#$ *,#$ $ $ :.;8.<7.9$ =7<>.978$ &!#$ :.;8.<7.9$ =7<>.978$ 9:;<-=>'()*+##,--.&/'0-"#$' &#$!#$ 3#$ $ $ :.;8.<7.9$ Figure

41 Comparison of self-reported education levels for participants in the ADTC Co-Occurring Track with evaluations in Buffalo (2007) and Lackawanna (2011)!"#$"%"&&"'()*+##,--.&/'0-"#$' 4,55"6)'()*+##,--.&/'0-"#$' +#$!#$ +#$!)#$ %3#$ *%#$ =7CA$D8AEE/FGHI$ DE20$:E//0C0$ :E//0C0$I0C600$ J9K9EL9$ (+#$ (3#$ *3#$ =7CA$D8AEE/FGHI$ DE20$:E//0C0$ :E//0C0$I0C600$ 9:;<-=>'()*+##,--.&/'0-"#$' (%#$!3#$ *!#$!!#$ =7CA$D8AEE/FGHI$ DE20$:E//0C0$ :E//0C0$I0C600$ J9K9EL9$ Figure

42 Comparison of the age of first substance use for participants in the ADTC Co-Occurring Track with Lackawanna!"#$"%"&&"'()*+##,--.&/'0-"#$' *,$ *&$ 9:;<-=>'()*+##,--.&/'0-"#$' *%$ ("$!*$ +$ ($!$ %$ +$ %$ J9K9EL9$ J9M06$!+$!"'()$ (!'(&$ (+'*)$ *!N$ J9KEL9$ '' Figure

43 Comparison of the primary drug used by participants in the ADTC Co-Occurring Track with evaluations in Buffalo (2007) and Lackawanna (2011)!"#$"%"&&"'()*+##,--.&/'0-"#$'!#$ 4,55"6)'()*+##,--.&/'0-"#$' )#$ %!#$ (3#$ ("#$ (!#$ )#$ +#$ +#$!,#$ %+#$ &#$ 9:;<-=>'()*+##,--.&/'0-"#$' *#$ (,#$ *%#$ 4/8EAE/$ Q09REM7.R.>090<$ :6.8KF:E8.790$!+#$!+#$ *#$ J9K9EL9$ Figure

44 Comparison of the primary mental health diagnosis for participants in the ADTC Co-Occurring Track with evaluations in Buffalo (2007) and Lackawanna (2011)!"#$"%"&&"'()*+##,--.&/'0-"#$' 4,55"6)'()*+##,--.&/'0-"#$' ' &#$ (#$ "#$ 3#$ (*#$ )#$!!#$ +#$!)#$!+#$ &%#$ &"#$ 9:;<-=>'()*+##,--.&/'0-"#$' "#$!#$ "#$ (*#$ Q7>E/.6$ *"#$ (&#$ I0>60<<7E9$ VWDI$ ' Figure

45 Inferential Observations of Amherst, Lackawanna, and Buffalo Lackawanna and Amherst Co-Occurring courts both had significant proportions of participants in the age range of years old; Amherst 43% and Lackawanna 44%, indicating a generally younger population Amherst had the highest proportion of female court participants by a significant margin. The ADTC was 48% female as compared to Lackawanna (27%) and Buffalo (40%). Amherst and Lackawanna had similar ethnic profiles and were comprised mainly of Caucasian participants. Amherst participants reported that 46% had college experience. This was significantly higher than Lackawanna (16%) and Buffalo (32%). Although different age matrices were used in the evaluation reports to analyze the age of first substance use, nearly all participants in Lackawanna (96%) had used substances before the age of 17. In contrast, only 69% of participants in Amherst had used substances by the age of 20. Amherst and Lackawanna participants had similar drugs of choice, which were primarily alcohol and opiates. This was in contrast to Buffalo where 46% of participants reported crack/cocaine as their primary drug of choice. Both Amherst and Lackawanna reported significant bipolar diagnoses for their participants. Interestingly, Amherst reported less depression than Lackawanna and Buffalo, but had more anxiety related diagnoses. 45

46 Amherst Court Grant Participants MINI and QLI Results Transfer Group Only 23 participants in the transfer group fully completed a MINI interview. Of these 23, 15 had scores of 6 or higher (65%) indicating the need for further evaluation for diagnostic assessment. Seven of the fifteen scored above a 9, reflecting a definite need for further mental health assessment. Figure 1.7 confirmed these diagnostic concerns as noted by 41% with bipolar illness, 34% with depression and 10% who were diagnosed with schizophrenia. Only 6 participants in the transfer group completed a QLI survey. Despite the small sample size, clear areas of concern were prevalent with an emphasis on the effect of drugs and alcohol on participant lives, as well as money concerns. Co-Occurring Track 67 out of 88 participants in the co-occurring track completed a MINI interview and 64 of those participants completed a Quality of Life survey. Again, Figure 1.7 confirms the concerns about participants with dual disorders (both substance and mental health diagnoses). This participant track of 88 individuals (confirmed by the treatment providers) showed 25% had bipolar illness, 37% had depression, 23% had anxiety, 7% had PTSD and 7% had other (eating disorders and personality disorders). These diagnoses strongly correlated with the MINI interview results, which indicated 31 participants scored a 6 or higher. This score indicates presumptive evidence of the need for further diagnostic evaluation. Quality of Life surveys indicated that the effect of drug and alcohol on their lives, and money issues affected participants the most. Additionally, involvement in employment, and involvement in the community were rated poorly by participants. 46

47 ADTC Goal Completion The ADTC grant narrative focused on three primary goals for the creation and incorporation of the Co-Occurring Disorders Track at the Amherst Drug Court, with each goal addressing one of the 10 Key Components of Drug Courts as defined by the Office of Justice Programs. Goal #1 was aimed at providing a higher likelihood of successful rehabilitation for individuals with a substance abuse and demonstrable co-occurring mental disorder. This goal was set to be accomplished in two parts, with the first being the creation of the COD track within the ADTC, and the second being the requisite training for ADTC staff to create a fully functioning COD track. The team set a goal of servicing offenders in the COD track during each year of the two-year grant period.! Goal #1 was accomplished as measured by the designation of 88 individuals as cooccurring and the transfer of 51 individuals to participating mental health courts. However, the designation of participants as having dual disorders did not occur until August 2011 in the last month of the grant, which means that these individuals were blended into the drug court population. Furthermore, members of the COD team were not able to confirm that additional services or increased case management were provided for these participants. Requisite training for ADTC staff was completed as demonstrated by attendance at several training sessions. Staff members attended two training symposiums hosted at Erie Community College. The first session was held April 9 th and 10 th, 2009 and was attended by COD team leader Carrie Frigon, drug court coordinator Jim Cavanuagh, and ADTC staff member Mary Anderson. Relevant training topics covered included: Working with participants diagnosed with co-occurring disorders 47

48 Culture and co-occurring disorders Post-traumatic stress disorder Understanding and coping with relapse Drug abuse recognition A second symposium was held April 8 th and 9 th, 2010 and was attended by COD team leader Carrie Frigon, drug court coordinator Jim Cavanaugh, drug court coordinator Eileen Logsdon, ADTC staff members Jim Loughran, Mary Armstrong, Judy Muzi, Carolyn Grisko, Jodi Altman, and the honorable Judge Mark Farrell. Relevant training topics included: Co-occurring challenges in criminal justice Mental health population in the jail system Post-traumatic stress disorder The ADTC case manager also attended the GAINS Center Conference in Orlando, FL on March 16-19, 2010 for training in identifying co-occurring disorders. A training session was also held with Dr. Grimm from American University on May 7 th, 2010 as requested by the BJA. This session was focused on reviewing best practices that had been outlined in previous evaluation studies for court procedures and practices dealing with dual disorder offenders. Additional training was received during attendance at the National Association of Drug Court Professionals Conference (NADCP) in Boston, MA from June 1 st -5 th, Goal #2 was also created in two parts with the overarching objective being to decrease the frequency of contact with the Criminal Justice System by participants in the co-occurring track by improving their social functioning through treatment, and the provision of case management and support services. This goal was to be accomplished by hiring a dedicated COD 48

49 team consisting of one full-time and one half-time staff member, diverting offenders with criminal cases pending in the Amherst Town Court system into the COD track, expanding linkages to specialized community treatment providers, and reducing recidivism by 70% among the participants in the COD track. A case manager from Horizons Health Care was hired as a full-time staff member on behalf of this grant. An additional half-time staff member was hired and subsequently fired two times and the position was not re-filled again. During Recovery Solutions court observations this case manager appeared to focus more on managing the high volume of ADTC participants, rather than case managing the COD track participants. In general, it did not appear that a dedicated, integrated COD team existed. Technically goal #2 was accomplished as measured by the 88 participants designated as having dual diagnosis disorders during the last month of the grant period. However, a true COD track did not appear to be created until the end of the grant period. Some linkages were created, including MOU s with ECC s Education 2 Recovery Program as well as Lackawanna, Tonawanda, and Niagara Falls Mental Health Courts. The stated objective of goal #3 was to determine the program s effectiveness in influencing criminal recidivism, program completion, number and type of service referrals, retention in mental health and related treatment, and operational outcomes related to community partnerships and programs. This goal was accomplished through the comprehensive evaluation services provided by Recovery Solutions. 49

50 Procedural Recommendations The following procedural recommendations are modeled after the process GAP analysis. Each process recommendation fulfills one of the 10 Key Component (KC) Characteristics of Effective Drug Courts as Developed by the National Association of Drug Courts Professionals (NADCP) Standards Committee in Intake 1 Make sure all court and treatment staff is trained in using the MIS Access Intake Database System and the Court Analyst run daily error reports to insure accuracy of information and follow up on any missing data. All intakes receive a full screening for alcoholism, drug disorders and mental health symptoms. Comprehensive information on prior treatments, legal history, prior problem solving court involvement, age of first use, age first arrest and age when experienced symptoms of emotional disturbance and trauma history needs to be gathered on all participants. All intakes complete the MINI Screening for Co-occurring Disorder during the initial screening session. Individuals scoring above a 6 on the MINI should be considered as needing a psychiatric evaluation as part of the treatment disposition, linkage and follow up decision making by the court team. Higher scores would raise stronger concerns about participant s severity of substance and mental health disorders. These cases should be targeted for either the 1 KC #1: To integrate drug treatment mental health services with justice case processing. KC #2: Using a non-adversarial approach, prosecutors and defense counsel promote public safety while protecting participant due process. KC #3: Eligible participants are identified early and promptly placed in the problem solving court projected to provide the highest prognosis of a successful outcome. KC #9: Continuing interdisciplinary education promotes effective problem solving court planning, implementation, and operations.) 50

51 co-occurring track or transfer to a mental health court for judicial case management. The report from the treatment provider should include recommendations for which court would best service the participant. It is recommended to use the Decision Making Matrix developed by Recovery Solutions for type of Problem Solving Court participation (See Appendix A). Database Collection and Analysis 2 Consistent, ongoing training to staff in using the Access MIS program. Training in the use of the American Society of Addiction Medicine (ASAM) PPC II criteria for level of care decision making for those with addictions disorders (ASAM, 2007) Training in the Brief Psychiatric Rating Scale (BPRS) (Overall & Gotham, 1962) and the Treatment Standards Manual (TSM III) (Mercurio, 2002) for both addictions and mental health client care determinations. Implementation of the Recovery Solutions Data Tracking Matrix (Appendix B) for data tracking and monitoring Judicial case management team meetings remain a high priority to review participant information gathering and the correlation to decision making 2 KC #4: Problem Solving Courts provide access to continuum of alcohol, drug, mental health and other related treatment and rehabilitation services. KC #6: A coordinated strategy governs program solving court responses to participant s compliance 51

52 Creation of a Separate Co-occurring Disorders Treatment Track 3 COD participants attend during the morning session on Problem Solving Court appearance days, along with the gambling and veterans participants, to allow for more individualized attention on their compliance with abstinence and treatment. This individualized time with the Judge reinforces the judicial case management, reinforces positive compliance, and negates the discomfort of the larger court participant audience, which may exacerbate the participant s psychiatric symptoms. Ideally, a separate morning or afternoon session for the COD participants is suggested. This is similar to how cases are handled in the Buffalo Mental Health Court. Given the similar diagnoses of a significant number of Amherst participants who are placed in COD care and the Transfer Group, the idea of a separate court session can only improve the outcomes. 3 KC #5: Abstinence is monitored by frequent alcohol and drug testing KC #7: Ongoing Judicial Interaction with each drug court participant is essential KC #8: Monitoring and evaluation measure the achievement of program goals and gauge effectiveness 52

53 Adding Ancillary Services 4 The Amherst Court needs to develop and implement on-site peer/alumni driven orientation sessions for those identified and recommended placement into the COD Court and those transferred to Mental Health Courts. This support sponsorship will assist with linkage compliance and court involvement. The Court should access the services of the Alliance for Mental Health and the Erie County Office of Mental Health Services to facilitate community care management services for those participants with severe mental illness, including supported housing. The Court needs to link participants identified through intake interviews and/or response to questions 14 and 15 on the MINI with community agencies providing trauma treatment services. Continued weekly screening by the Erie Community College Education 2 Recovery staff for academic and vocational services. Request E2R facilitate participant enrollment in other local 4-year colleges and workforce development re-training programs, as many court participants already have degrees and are working. The Education 2 Recovery Program also provide screenings for non-custodial parents with Child Support and Custody Family Court cases to facilitate compliance issues and re-unite parents with their child through the DADS and MOMS Programs. These recovery activities assist in the recovery process and increase participant self-esteem. These issues are often reflected on the Quality of Life Inventory. 4 KC #10: Forging partnerships among drug courts, agencies and community based organizations generates local support and enhances problem solving court program effectiveness 53

54 Direction for Future Research and Enhancement As indicated in this evaluation, we were not able to interview a sample of the cooccurring disorders population because they were not identified until the last month of the grant. Participant interviews as well as longitudinal studies examining successful COD track graduates, as well as failed COD track participants may help determine thematic indicators of success or failure. Additionally, a larger scale project could be conducted that examines statistics from all three Western New York co-occurring courts to provide further statistical relevance to thematic indicators. This study could also create a best practices model for co-occurring disorders in the WNY area. The Recovery Solutions Decision Making Matrix for type of problem solving court participation and the Recovery Solutions Statistical Data and Outcome Tracking Matrix should be utilized in Amherst as well as surrounding co-occurring and mental health courts. We also suggest forming a consortium of local professionals to formulate a co-occurring disorders task force. This group could include Judges and staff from local co-occurring courts, treatment staff, community agencies, educational institutions, the Erie County Department of Mental Health, and the Mental Health Peer Advocacy Group. A best practices model for effectively addressing the unique needs of the co-occurring disorders population could be created with the idea of coordinating systemic and seamless linkages between the justice system and community providers. This group could also link to the Center for Court Innovation out of New York City who publishes research on problem solving courts and emerging best practices. 54

55 Works Cited Aharonovich, E., Liu, X., Nunes, E., & Hasin, D. (2002). Suicide attempts in substance abusers: Effects of major depression in relation to substance use disorders. American Journal of Psychiatry, 159, American Society of Addiction Medicine (ASAM). (2007). ASAM patient placement criteria for the treatment of substance-related disorders, second edition-revised. Center City, MN: Hazelden Publishing. Center for Substance Abuse Treatment. (2005). Substance abuse treatment for persons with co-occurring disorders. Treatment Improvement Protocol (TIP) Series, No. 42. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Ferrer, J. (2001). Buffalo DMIS-2001 management information system. Buffalo, NY: Microsoft ACCESS Programming. Frisch, M. B. (1992). Clinical validation of the quality of life inventory: A measure of life satisfaction for use in treatment planning and outcome assessment. Psychological Assessment. 4, James, J.D. & Glaze, L. E. (2006). Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Bureau of Justice Statistics. Maisto, S. A., & Kivlahan, D. (2008). Screening for Psychiatric Disorders among Adults Presenting for Substance Use Disorder Treatment: Current Practices in the United States. International Journal of Mental Health Addiction, 6,

56 Mercurio, J. (2002). Treatment standards manual III. Orchard Park, NY: Spectrum Human Services Foundation. Minkoff, M.D., K. (2001). Developing Standards of Care for Individuals With Cooccurring Psychiatric and Substance Use Disorders. Psychiatric Services, 52, National Association of Drug Court Professionals (NADCP). (1997). Defining drug courts: The key components. Washington, DC: United States Department of Justice, Office of Justice Programs Overall, J. E. & Gotham, D. R. (1962). The brief psychiatric rating scale. Psychological Reports. 10: Sheehan, D.V., et al. (1998). The mini-international neuropsychiatric interview (mini): Development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICS-10. Journal of Clinical Psychiatry. 59. Substance Abuse and Mental Health Services Administration. (2009). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. Rockville, MD, Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA Findings. The National Association of State Alcohol and Drug Abuse Directors and the National Association of State mental Health Program Directors. (2005). The evolving conceptual framework for co-occurring mental health and substance abuse disorders: Developing strategies for systems change. Final report of NASMHPD-NASADAD Task Force on Co-occurring Disorders 56

57 Washousky, R. (2007). Buffalo drug court co-occurring disorder evaluation. Buffalo, NY: Recovery Solutions, Inc. Washousky, R. (2007). Psychiatric illness among drug court participants: A pilot study at the buffalo drug court. ABD. Buffalo, NY, Recovery Solutions, Inc. Washousky, R. & Washousky, D. (2011). Lackawanna drug treatment court co-occurring disorders treatment track: Genesis, creation, and evaluation. Buffalo, NY: Recovery Soultions, Inc. 57

58 Substance Abuse History With: Appendix A: Recovery Solutions Decision Making Matrix Indicators Drug Court Co-occurring Court Mental Health Court MINI Score of 6 or less MINI Score of 6 or less and a positive response to Q4 MINI Score of 6 or less and positive responses to Q14 and Q15 (Screen for trauma services needed) X X X X X X MINI Score of 6-8* X X MINI Score of 9+* X QLI with a response to Q16 of poor* X X QLI with ratings on Q8, Q10, Q12, Q16 as poor* X X Substance Abuse History and Mental Health Demographic & Treatment Information: Age of first use <10 + age of first arrest <15 X X Trauma history; physical and/or sexual abuse before age 10 X X By intake history proir inpatient or outpatient Mental Health Treatment X X By intake history self or confirmed diagnoses of Depression and Borderline Personality Disorder mild to moderate severity X Confirmed diagnoses of schizophrenia, depression severe, bipolar disorder moderate to severe X Participant expressed and/or evaluator recognized emotional disturbances in affective, cognitive, perceptual, and social factors (e.g. cases on SSI or SSD for mental health*) X X Decision matrix is to be used as a guide by intake court and treatment professionals as presumptive evidence for initial type of court participant involvement. Further research of using and measuring outcomes is needed. Software program could be written to provide an immediate court participation recommendation at the completion of the intake evaluation by Recovery Solutions, Inc. *These participants should be given the Brief Psychiatric Rating Scale (BPRS) accessed as a link to the Decision Making Matrix to further assess and provide the treatment provider with severity of psychiatric symptomology across 18 indicators: somatic concern, anxiety, emotional withdrawal, conceptual disorganization, guilt feelings, tension, mannerisms and posturing, grandiosity, depressive mood, hostility, suspiciousness, hallucinatory behavior, motor retardation, uncooperativeness, unusual thought content, blunted affect, excitement and disorientation (See Reference). 58

59 Appendix B: Recovery Solutions Data Tracking Matrix PARTICIPANT DATE PARTICIPANT NAME SEX DOB ETHINICITY MINI QUALITY OF LIFE AXIS 1 DX PROGRAM STATUS 1/1/11 Smith, Joe M 6/6/86 Caucasian Y N Bipolar; Cocaine Active PARTICIPANT DATE PARTICIPANT NAME EDUCATION LEVEL AT ADMISSION Y/N HISTORY OF ABUSE EMOTIONAL PHYSICAL SEXUAL AGE OF 1ST ARREST # OF RE-ARRESTS WITHIN 24 MO AGE OF FIRST SUBSTANCE USE 1/1/11 Smith, Joe HSD N Cocaine Y DRUG OF CHOICE HISTORY OF CHEMICAL DEPENDENCY PREVIOUS TX PROGRAMS # OF DAYS IN EACH PROGRAM INPATIENT OUTPATIENT RESIDENTIAL Phoenix House 112 Southern Eire Clinical Services 21 ADDS 8 Turning Point 8 59