Transcript NIMH Co-Occurring Disorders Curriculum

What Does the Research Tell
Us about Treating Offenders
with Substance Use or CoOccurring Mental Disorders?
2014 FADAA/FCCMH Annual Conference
Orlando, Florida; August 6, 2014
Roger H. Peters, Ph.D., University of South Florida
[email protected]
Goals of this Presentation
Review:
• Evidence-based interventions for treating offenders
who are substance-involved or who have cooccurring mental disorders
• Review risk-need-responsivity, cognitive-behavioral,
and social learning approaches for treating offenders
who have behavioral health disorders
• Identify practice implications of using these
approaches with offenders
Resources
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NDCI/NADCP http://www.ndci.org/
SAMHSA’s GAINS Center
http://gainscenter.samhsa.gov/
CSAT TIP #42 and #44
http://www.ncbi.nlm.nih.gov/books/NBK8
2999/
Council of State Governments - Justice
Center http://csgjusticecenter.org/
Resources
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SAMHSA/CMHS Toolkit on Integrated
Treatment for Co-Occurring Disorders
http://store.samhsa.gov/product/Integrated
-Treatment-for-Co-Occurring-DisordersEvidence-Based-Practices-EBPKIT/SMA08-4367
National Institute on Drug Abuse (NIDA)
http://www.drugabuse.gov/
What Doesn’t Work in
Offender Treatment?
 Incarceration without treatment
 Supervision without intensive treatment
 Self-help without intensive treatment
 Drug education
 Films
 Building self-esteem as primary focus
 Targeting participants with low criminal risk or
with mild substance use disorders
 Mixing high risk and low risk participants
 Non-manualized treatment
Evidence-Based Models for
Offender Treatment
Evidence-Based Models to
Guide Offender Treatment
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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)
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’
Using Risk and Needs to Guide
Offender Treatment
• Focus resources on Moderate to High Risk cases
(risk for criminal recidivism)
• Interventions should target Dynamic Risk Factors
for criminal recidivism (e.g., antisocial attitudes,
criminal peers, substance abuse)
• Focus on those who have High Needs for
substance abuse treatment
• Providing intensive treatment and supervision for
low risk drug offenders can increase recidivism
• Mixing risk levels is contraindicated
Dynamic Risk Factors for
Criminal Recidivism
1. Antisocial attitudes
2. Antisocial friends and peers
3. Antisocial personality pattern
4. Substance abuse
5.
6.
7.
8.
Family and/or marital problems
Lack of education
Poor employment history
Lack of prosocial leisure activities
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Responsivity
Strategies to tailor treatment and supervision to
help offenders engage in evidence-based
interventions that address dynamic risk factors
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Mental health treatment
Trauma/PTSD services, gender-specific treatment
Motivational enhancement techniques
Address language and literacy issues
Use of cognitive-behavioral approaches
How is Level of Risk
Determined?
• Risk for criminal recidivism
• Use of risk assessment
- ‘Static’ factors (e.g., criminal history)
- ‘Dynamic’or changeable factors that are targets of
interventions in the criminal justice system
Risk Assessment Instruments
Historical-Clinical-Risk Management - 20 (HCR-20)
Level of Service Inventory - Revised – Screening Version (LSI-R-SV)
Ohio Risk Assessment System (ORAS)
Psychopathy Checklist - Screening Version (PCL-SV)
Risk and Needs Triage (RANT)
Short-Term Assessment of Risk and Treatability (START)
Violence Risk Scale (VRS): Screening Version
Integrating Treatment and Supervision Reduces Risk
National Reentry Resource Center, 2012
Evidence-Based Screening and
Assessment
Importance of Screening and
Assessment for CODs
 High
prevalence rates of behavioral health
and related disorders in justice settings
 Persons
with undetected disorders are likely
to cycle back through the justice system
 Allows
for treatment planning and linking
to appropriate treatment services
 Offender programs using comprehensive
assessment have better outcomes
Key Screening Domains for
Co-Occurring Disorders
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Mental disorders
Substance use disorders
Trauma/PTSD
Suicide risk
Motivation
Criminal risk level
Alcohol, Smoking,
and Substance
Involvement
Screening Test
(ASSIST)
Substance
Use
Screening
Instruments
Simple
Screening
Instrument
(SSI)
Texas
Christian
University
Drug Screen-II
(TCUDS-II)
Correctional
Mental
Health
Screen
(CMHS)
Mental
Health
Screening
Instruments
Mental
Health
Screening
Form-III
(MHSF-III)
Correctional
Mental Health
Screen (CMHS)
and Texas
Christian
University Drug
Screen-II
(TCUDS-II)
Screening
Instruments
for CoOccurring
Disorders
Mini
International
Neuropsychiatric
Interview-Screen
(MINI Screen)
Screening for Trauma and PTSD
• All offenders should be screened for trauma
history; rates of trauma > 75% among female
offenders and > 50% among male offenders
• The initial screen does not have to be conducted by
a licensed clinician
• Many non-proprietary screens are available
• Positive screens should be referred for more
comprehensive assessment
Trauma and PTSD Screening Issues
• PTSD and trauma are often overlooked
in screening
• Other diagnoses are used to explain
symptoms
• Result - lack of specialized treatment,
symptoms masked, poor outcomes
Trauma
History
Screen
(THS)
Life
StressorChecklist
(LSC-R)
Posttraumatic
Symptom
Scale (PSS-I)
Trauma and
PTSD
Screening
and
Assessment
Instruments
Posttraumatic
Diagnostic
Scale (PDS)
Primary Care
PTSD Screen
(PC-PTSD)
PTSD
Checklist –
Civilian
Version
(PCL-C)
Personality
Assessment
Inventory
(PAI)
Alcohol Use
and Associated
Disabilities
Interview-IV
(AUDADIS-IV)
Instruments
to Assess and
Diagnose CoOccurring
Disorders
MINI
International
Neuropsychiatric
Interview (MINI)
Structured
Clinical
Interview
for DSM-5
(SCID-5)
Evidence-Based Offender
Treatment for SUDs and CODs
Evidence-Based Treatment
Interventions for Offenders
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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)
Drug Courts
• Meta-analyses indicate that drug courts lead to
reductions in recidivism from 8-26% vs. comparisons
- Drug court effects on recidivism extend to at least
36 months (Mitchell et al., 2012)
- Wide variation in effect size; 15% of programs
ineffective
• Drug courts produce cost benefits of $4,767 - $5,680 per
participant (Aos et al., 2006; Rossman et al., 2011)
Prison Treatment and Reentry
50
40
30
33%
20
MH
10
16%
TC only
0
Total n=139
Sacks et al. 2004
n=64
n=32
TC +
aftercare
5%
n=43
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Kelly, Finney, & Moos, 2005
Effectiveness of Outpatient
Treatment with Offenders
• Outpatient treatment of probationers leads to
fewer arrests at 12 and 24 month follow-up
(Lattimore et al., 2005) vs. untreated
probationers
• High-risk probationers in outpatient treatment
experience 10-20% reductions in recidivism
(Petersilia & Turner, 1990, 1993)
• Reductions in recidivism durable for 72
months after treatment (Krebs et al., 2009)
Optimal Duration of
Outpatient Treatment
• At least 3 months of outpatient treatment needed
• Greatest effects for outpatient treatment of 6-12
months
• Diminishing outcomes for treatment lasting > 1 year
• Best outcomes for persons completing treatment
Outpatient vs. Residential
Treatment
• Both outpatient and residential treatment are
effective for offenders
• Outpatient treatment is more effective than
residential treatment for drug-involved probationers
(Krebs et al., 2009) and during reentry (Burdon et
al., 2004)
• Cost-benefit analysis
• Greater benefits for outpatient treatment in non-offender
samples (e.g., CALDATA, French et al., 2000, 2002)
• Excellent benefit-cost ratio for intensive supervision +
treatment, community TC, community outpatient, and
drug court programs (Aos et al., 2001; Drake et al., 2009)
Aftercare/Continuing Care
• Aftercare services among drug-involved offenders can
significantly reduce substance use and rearrest
(Butzin et al., 2006)
• Outpatient aftercare services can reduce likelihood of
reincarceration by 63% (Burdon et al., 2004)
• Aftercare services provide $4.4 - $9 return for every
dollar invested (Roman & Chalfin, 2006)
• Promising interventions for high risk/high need
offenders
• Recovery management checkups (Rush et al., 2008)
• Critical time intervention (Kasprow & Rosenheck,
2007)
Adaptations for COD Treatment
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Destigmatize mental illness
Focus on symptom management vs. cure
Focus on education/support vs. compliance/sanctions
Higher staff-to-participant ratio, more structure
Dually credentialed staff
Increased length of services ( > 1 year)
Pace of treatment slower
Motivational interventions
Cognitive and memory enhancement strategies
Focus on housing, employment, medication needs
Evidence-Based Integrated
COD Treatment Curricula
• Illness Management and Recovery (IMR)
• Integrated Group Therapy for Bipolar
Disorder and Substance Abuse
• Integrated Cognitive-Behavior Therapy
(ICBT)
• Seeking Safety (SA and trauma/PTSD)
Structural COD Interventions
• Assertive Community Treatment (ACT)
• Residential Treatment (Therapeutic
Communities; TCs) modified for CODs
- More flexibility
- Less confrontation
- Greater individualization of services
- More staff involvement
- Longer duration
• Case management and legal coercion – assist in
treatment retention
• Supported housing
Specialized Supervision Caseloads
• Specialized MH/COD caseloads
• Smaller caseloads with more intensive services (e.g.,
< 45)
• Sustained and specialized officer training
• Dual focus on treatment and surveillance
• Active engagement in SA and MH services