Transcript NIMH Co-Occurring Disorders Curriculum

Roger H. Peters, Ph.D.,
University of South Florida; [email protected]
Co-Occurring Disorders 102
Goals of this Presentation
Review:
• Available screening instruments
• Conceptual model to drive COD
services (Risk-Need-Responsivity)
• Treatment modifications for CODs
• Special populations and CODs
2
Defining “Co-Occurring
Disorders”
The presence of at least two disorders:
 A substance abuse or dependence
disorder
 A DSM-IV major mental disorder,
usually Major Depression, Bipolar
Disorder, or Schizophrenia
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Survey Results:
Offender Screening
 Wide
variation in types of SA
screening instruments administered
 32% of sites used no SA screening
instruments
 42% of sites did not use a
standardized SA screening
instrument
(Taxman et al., 2007)
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Screening for CODs
• Routine screening for both sets of disorders
• Criminal risk level
• Acute MH and SA symptoms:
• Suicidal thoughts and behavior
• Depression, hallucinations, delusions
• Potential for drug/alcohol withdrawal
• History of MH treatment including use of
meds
• Determine need/urgency for referral
Screening—Mental Health
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Brief Jail Mental Health Screen
Mental Health Screening Form–III
MINI–M
CODSI (Sacks et al, 2007)
GAIN–SS
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Screening—Substance Abuse
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Simple Screening Instrument
TCU Drug Screen–II
ASI–Alcohol and Drug Abuse sections
GAIN–SS
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Screening—Trauma and PTSD
• Clinician-Administered PTSD Scale for
DSM-IV
• Impact of Events Scale
• Primary Care PTSD Screen
• PTSD Checklist–Civilian Version
• Trauma Symptom Inventory
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Specialized Screens
• BASIS-24
• Centre for Addiction and Mental Health
Concurrent Disorders Screener (CAMHCDS)
• Psychiatric Diagnostic Screening
Questionnaire (PDSQ)
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Instruments for
Adolescents
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CAFAS
GAIN
MAYSI-2
PESQ
POSIT
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Other Screening Domains
• Motivation
• Offender Risk and Needs
• Trauma and PTSD
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Instruments—Motivation
and Stages of Change
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CMRS
RCQ
SOCRATES
TCU Treatment Motivation Scales
URICA
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Instruments—Offender Risk
and Needs
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HCR-20
LCSF
LSI-R
PCL-SV
RANT
START
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Trauma and Victimization
• Female offenders frequently have been
victims of physical or sexual violence
• Trauma history—should be expectation
for women in CJ settings
• Impact of violence is widespread, can
impair recovery from MH and SA
disorders
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
Screening for Trauma and
PTSD
• All women should be screened for trauma
history across different justice settings
• Initial screen does not have to be conducted
by a mental health clinician; doesn’t require
discussion of specific details
• Many simple, non-proprietary screening
instruments available
• Positive screens should be referred for more
comprehensive assessment
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Screening Instruments for
Trauma and PTSD
• Clinician-Administered PTSD Scale for
DSM-IV (CAPS)
• Impact of Events Scale (IES)
• Primary Care PTSD Screen (PC-PTSD)
• PTSD Checklist—Civilian Version (PCLC)
• Trauma Symptom Inventory (TSI)
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Admission Criteria and
CODs
• Excluding persons with CODs is NOT a viable
option
• How to determine eligibility for services?
• Triage to specialized COD services
• Target moderate to high criminal risk levels
Assessing Program
Eligibility
1. Review existing program resources to work
with co-occurring disorders
 Staff with MH and SA treatment experience
 Linkages with institutional and communitybased MH and SA services
 Specialized “tracks,” groups, or other
services for co-occurring disorders
 Psychiatric/medication consultation
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Assessing Program
Eligibility
2. Determine functioning level required for
program participation
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Treatment groups
Therapeutic communities
Community supervision
Employment and peer support
programs
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Assessing Program
Eligibility
3. Examine broad categories of functioning
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Cognitive functioning
Major mental health symptoms
Unusual behaviors
Ability to interact with staff and
participants (e.g., group settings)
How responds to stress
Reading, language abilities
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Key Assessment Information
• Scope and severity of MH and SA disorders
• Pattern of interaction between the disorders
• Conditions associated with occurrence and
maintenance of the disorders
• Criminal-antisocial beliefs
• Motivation for treatment
• Family and social relationships
• Physical health status and medical history
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Conceptual Model of Services
Matching by Risk Level
• Use of risk assessment instruments
• Triage to different levels of treatment, judicial
monitoring, and supervision
Reentry Services
Higher Risk Populations
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• Greater criminogenic needs
• CODs
Specialized
Supervision
Caseload
Alumni groups
Contingent early release
Relapse prevention planning
Reentry courts
Offender Treatment
Cog.-Behav. Treatment
Social Learning Approaches
Criminal Thinking
MET/MI
Conting. Management
Specialized Treatments
 Illness Management & Recovery
(IMR), Integrated Group Therapy (IGT)
Seeking Safety
Risk-Need-Responsivity
(RNR)
• The RISK principle tell us WHO to
target
• The NEED principle tells us WHAT to
target
• The RESPONSIVITY principle tells us
HOW to target
“Risk” Principle
• Goal is to match the level of services to
the offender’s likelihood to re-offend
• Provides guidance re. WHO to target for
program interventions
• Adjust interventions, structure, and
supervision by risk level
“Need” Principle
• Assess criminogenic needs and
address these needs through focused
interventions
• Place higher-risk/higher-need offenders
in treatment services
• Prioritize a person’s “high” needs in
coordinating services
Criminogenic Needs
Dynamic or changeable factors that
contribute to the likelihood that
someone will commit a crime
“People involved in the justice system
have many needs deserving
treatment, but not all of these needs
are associated with criminal behavior”
Andrews & Bonta (2006)
Criminogenic Needs—“Big 8”
1. Antisocial attitudes
2. Antisocial friends and peers
3. Antisocial personality pattern
4. Substance abuse
5.
6.
7.
8.
Family and/or marital factors
Lack of education
Poor employment history
Lack of prosocial leisure activities
Interventions
Cognitive skills to address ‘criminal
thinking’, positive peer supports, problemsolving skills
Interventions
Substance abuse treatment
Co-occurring disorders treatment
Job training/employment readiness
“Responsivity” Principle
• Optimizing offenders’ engagement,
learning, and skill-building
• Allows offenders to respond effectively
to interventions
Responsivity—
general strategies
• General approaches for providing
interventions for offenders with CODs
- Cognitive-behavioral
- Social learning
Responsivity—
fine tuning
• Fine tuning interventions based on:
- Individual strengths and abilities
- Learning style
- Psychological functioning (e.g., CODs)
- Motivation level
- Gender (e.g., with history of trauma/PTSD)
- Race/ethnicity
Key Features of COD
Treatment Programs
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Highly structured therapeutic approach
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 problemsolving skills
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Structural Features of Offender
Treatment Programs
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Therapeutic communities
Isolated treatment units
Program phases
Blending of MH and SA services
Assessment
Specialized mental health services
Transition and reentry services
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Stage-Specific Treatment
• People with CODs who have had contact with
the CJ system come to treatment with varying
degrees of readiness and motivation
• Assessment of individuals’ stages of change
is valuable in treatment planning
• Allows development of stage-specific
treatment for co-occurring disorders
• Interventions are more likely to address goals
that are valued by the individual
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COD Program Phases
 Orientation
 Intensive treatment
 Relapse prevention/transition
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Orientation Phase
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Comprehensive assessment
Persuasion and engagement
groups
Treatment plan or contract
Introduction to recovery process
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Intensive Treatment Phase
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Individual and group treatment
Broad array of cognitive-behavioral
interventions
Specialized dual diagnosis
interventions
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Relapse Prevention/
Transition Phase
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Education about the relapse
process
Relapse prevention plan
Transition plan
Case managers or transition
coordinators
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Treatment Modifications
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Longer duration of treatment
More extensive assessment
Emphasis on psychoeducational
and supportive approaches
Higher staff ratio, more MH staff
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Treatment Modifications
 Shorter meetings and activities
 Information presented gradually, in
small units, and with repetition
 Supportive versus confrontational
approach
 More time provided for engagement and
stabilization
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Modifying Treatment for
Cognitive Impairment
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Minimize need for abstraction (e.g.,
use concrete, specific scenarios)
Have demonstrate skills
Keep instructions brief
Use audiovisual aids
Keep role plays short and focused
(Bellack, 2003)
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Treating Female Offenders
with CODs
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Focus on trauma and spousal abuse
Emphasis on education and job training
Parenting skills
Female role models and peer support
Assertive outreach and crisis
intervention
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Treatments for Trauma and
Substance Abuse
• Seeking Safety (Najavits, 2002)
• Trauma Recovery and Empowerment
(TREM) (Harris, 1998)
• Treating concurrent PTSD and cocaine
dependence (Brady et al., 2001)
• Substance Dependence Posttraumatic Stress
Disorder Therapy (Triffleman, et al., 1999)
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Key Transition Services
• Development of re-entry or transition plan
• Assistance to engage in community-based
SA and MH treatment
• Engagement in peer support and self-help
networks to assist in recovery
• Stable housing
• Vocational training and employment support
• Case management and community
supervision
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The APIC Model
• Assess clinical and social needs and
risk level
• Plan for treatment and services
• Identify required community programs
• Coordinate the transition plan services
(Osher, Steadman, & Barr, 2002)
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APIC Reentry Checklist:
Primary Domains
♦ Mental health services
♦ Psychotropic medications
♦ Housing
♦ Substance abuse services
♦ Health care/benefits
♦ Income/benefits
♦ Food/clothing
♦ Transportation
♦ Other
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Effectiveness of Prison COD Treatment
and Reentry—1 Year Reincarceration
50
40
30
33%
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MH
TC +
aftercare
5%
16%
10
TC only
0
Total n=139 n=64
Sacks et al. 2004
n=32
n=43
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Court Hearings and Judicial
Monitoring
• More frequent court hearings may be needed
• Hearings provide a good opportunity to
recognize and reward positive behavioral
change
• Specialized dockets
- Less formal, smaller, more private
- More frequent
- Greater interaction between judge and
participants
- Include mental health professionals
Community Supervision
• Active involvement in court and community
treatment teams, in-reach to jail and prison
• Rapid crisis response capability
• Monitor medication compliance (MH
agencies)
• Home visits useful
• “Fugitive” warrants receive priority
• Taper supervision over time
Specialized 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
Specialized Caseloads
• Relationship quality important (trust, caringfairness, avoid punitive stance)—“firm but fair”
• Problem-solving approach vs. reliance on
sanctions
• Wide range of incentives and sanctions
• Flexibly apply sanctions
• Avoid sanctions that remove participants from
treatment
• Higher revocation threshold
• Improved outcomes—lower rates of revocation,
arrest, and incarceration (Skeem et al., 2009)