Goals of this Presentation

1. 2014 FADAA/FCCMH Annual ConferenceOrlando, Florida; August 6, 2014Roger H. Peters, Ph.D., University of South Florida rhp@usf.edu What Does the Research Tell Us about Treating Offenders with Substance Use or Co-Occurring Mental Disorders?

2. Goals of this Presentation Review: • Evidence-based interventions for treating offenders who are substance-involved or who have co-occurring 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

3. Resources • 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/NBK82999/ • Council of State Governments - Justice Center http://csgjusticecenter.org/

4. Resources • SAMHSA/CMHS Toolkit on Integrated Treatment for Co-Occurring Disorders http://store.samhsa.gov/product/Integrated-Treatment-for-Co-Occurring-Disorders-Evidence-Based-Practices-EBP-KIT/SMA08-4367 • National Institute on Drug Abuse (NIDA) http://www.drugabuse.gov/

5. 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

6. Evidence-Based Models for Offender Treatment

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

8. 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’

9. 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 Using Risk and Needs to Guide Offender Treatment

10. Dynamic Risk Factors for Criminal Recidivism Antisocial attitudes Antisocial friends and peers Antisocial personality pattern Substance abuse Family and/or marital problems Lack of education Poor employment history Lack of prosocial leisure activities

12. Strategies to tailor treatment and supervision to help offenders engage in evidence-based interventions that address dynamic risk factors Mental health treatment Trauma/PTSD services, gender-specific treatment Motivational enhancement techniques Address language and literacy issues Use of cognitive-behavioral approaches Responsivity

13. 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 How is Level of Risk Determined?

14. Risk Assessment Instruments

15. Integrating Treatment and Supervision Reduces Risk National Reentry Resource Center, 2012

16. Evidence-Based Screening and Assessment

17. 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

18. Key Screening Domains for Co-Occurring Disorders • Mental disorders • Substance use disorders • Trauma/PTSD • Suicide risk • Motivation • Criminal risk level

22. 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

23. 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

26. Evidence-Based Offender Treatment for SUDs and CODs

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

28. Drug Courts • Meta-analysesindicate 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)

29. Prison Treatment and Reentry 33% MH TC +after-care 16% 5% TC only Total n=139 n=64 n=32 n=43 Sacks et al. 2004

30. 31 Kelly, Finney, & Moos, 2005

31. 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)

32. 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

33. 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)

34. 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)

35. Adaptations for COD Treatment • 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

36. 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)

37. 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

38. 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