Co-Occurring Disorders, Veterans & the Justice System

1. Co-Occurring Disorders, Veterans & the Justice System

2. Sponsored by The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT) and Center for Mental Health Services (CMHS) through the Co-Occurring Disorders Integration and Innovation Task Order

3. Stay Connected • Visit the Co-Occurring Disorders Integration and Innovation (CODI) Web site at http://coce.samhsa.gov for key CODI resources, events, trainings and learning tools • Visit the Substance Abuse and Mental Health Services Administration (SAMHSA) Web site at http://www.samhsa.gov/ for other valuable resources. • Join the CODI List Serve to receive event announcements, product debuts, and much more. • Send an email to contact@codimail.org with “Subscribe”.

4. Presentation Overview • National and Community Priority • Veterans in the Justice System • Addressing Co-Occurring Disorders in Justice Settings • Risk Factors • Screening • Systems and Services Integration • Management and Supervision

5. (1) National Priority

6. (1) Strengthening Our Military Families “Enhance the well-being and psychological health of the military family • “By increasing behavioral health services through prevention-based alternatives and increasing community-based services • “By ensuring availability of critical substance abuse prevention, treatment, and recovery services for Veterans and their families • “By making our court systems more responsive to the unique needs of Veterans and families”

7. (1) Leading Change Military Families Strategic Initiative • “Supporting America’s service men and women—Active Duty, National Guard, Reserve, and Veteran—together with their families and communities by leading efforts to ensure that needed behavioral health services are accessible and that outcomes are positive.”

8. (1) A Court-Based Response • Veterans Treatment Courts • Growth • 50 courts established since the first docket was established in January 2008 • Legislation • Illinois, Nevada, and Texas • Similar legislation passed in California and Minnesota granting judges the discretion to order a veteran with combat-related behavioral health service needs into treatment in lieu of prison

9. (2) What are the reasons for focusing on veterans in the justice system?

10. (3) Criminal Justice & Co-Occurring Disorders • A non-addictive mental disorder occurring simultaneously and independently with an addictive disorder • Community corrections agencies are a major source of referrals for community-based substance abuse treatment • Three quarters of jail inmates with a mental disorder have a co-occurring substance use disorder

11. (3) Failure to Address COD • Non-integrated approaches result in poor outcomes • Lack of treatment engagement and adherence • Continued use of ER, inpatient hospitalization • Continued contact with criminal justice system • Symptom recurrence • Inappropriate treatment recommendations • Overuse of medications • Problems in working, family, and social roles • Medical problems

12. (3) Prevalence of COD in Justice Settings • Serious mental illness among jail inmates • Axis I—schizophrenia spectrum, bipolar disorder, major depression • 15% for men • 31% for women • Co-occurring substance use disorder • 72% to 75% • 13 million jail admissions between midyears 2008 and 2009 • 1 million are of people with co-occurring disorders

13. (4) 2 Million Deployed Since 2001 • Stressors facing veterans of OEF/OIF • Long deployments • Multiple deployments • Reduced dwell time • Behaviors adapted for the combat zone don’t transition well to civilian life • National Guard and Reservists have less support than Active Duty • Rapid demobilization • Loss of support from unit peers

14. (4) Readjustment to Civilian Life • Family strife • Unemployment • Access to alcohol and drugs • Hyper vigilance • Difficulty talking to anyone but unit peers • Maintaining operational secrecy • Access/willingness to use VA services • TRICARE not offered by many healthcare providers • Concerns with receiving behavioral healthcare

15. RAND Survey of 1,965 returning veterans 18.5% had a mental illness 19.5% had a traumatic brain injury Post Deployment Health Assessments PTSD increases by 40% for Active Duty and 90% for National Guard/Reserve in six months after returning home (4) PTSD & TBI among OEF/OIF

16. (5) Screening for Military Service • Are you a veteran? • Have you ever served in the U.S. Armed Forces?

17. (5) Types of Screens • Co-occurring disorders • Trauma and PTSD • Criminal risk and need

18. Factors that affect eligibility Active military service Reservists and National Guard members called to active duty Discharge status Resources vary by priority groups Returning OEF/OIF have 5 years after discharge date Only 40% of eligible veterans use VA services (6) Eligibility for VA Health Services

19. Veterans Integrated Service Networks VA Medical Centers Community Based Outpatient Clinics Vet Centers (6) Veterans Health Administration

20. Network Level Network Homeless Coordinators Facility Level OEF/OIF Coordinators/Point of Contact Veterans Justice Outreach Specialist Vet Centers (6) Developing Linkages with VA

21. Criminal Justice Judges, Prosecutor’s Office, Public Defender’s Office, Court Administration, Law Enforcement, Jail, Probation Behavioral Health County/City Behavioral Health Agency(ies) and Providers, Homeless Service Providers Veteran Organizations Veterans Service Organizations, Vet Center, VAMC/CBOC, VISN, National Guard, Military Family Organizations, Veteran Peer to Peer Providers (6) Community Partners

22. Both disorders are primary Expect co-occurring disorders No wrong door Integration of treatment services Individualized programming Treatment comprehensiveness and flexibility Focus on motivation and engagement Graduating the intensity of treatment Service continuity Recovery support (7) Principles of Addressing COD in Justice Settings

23. Integrated approach needs to address Co-occurring disorders Criminal risks and needs Needs specific to veterans status (i.e., service-related injury and disability) Need to address all three domains Lack of focus on co-occurring disorders will result in poor program outcomes, including non-adherence to treatment and supervision plans (7) Integrated Approach for Justice-Involved Veterans with COD

24. (7) Case Management • Effective case management strategies for justice-involved people with co-occurring disorders • Focus on multiple needs—behavioral, medical, criminogenic, disability • Motivational over confrontational approaches • Graduated sanctions • Provide support around daily activities • Monitor attendance and compliance with treatment • Work with supportive family members • Respect the role of probation/parole supervision, court monitoring and reporting

25. Establish a common language between behavioral health providers, criminal justice agencies, and VA Develop treatment, supervision, and reporting plans that are agreed upon by all parties Establish a graduated sanctions plan that may or may not include jail days Use treatment practices that address co-occurring disorders and criminogenic risks and needs Case managers and community corrections officers may need smaller staff to client ratios (7) Team Approach

26. Is linkage to the VA a viable option? Does the veteran have private insurance, Medicaid, or TRICARE? How will you address trauma? Does this justify a new program or a recalibration of a current program? How can this be conducted using an integrated approach? Guiding Questions