2014 FADAA/FCCMH Annual ConferenceOrlando, Florida; August 6, 2014

Roger 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?

Goals of this Presentation

Review:• Evidence-based interventions for treating offenders Evidence-based interventions for treating offenders

who are substance-involved or who have co-who are substance-involved or who have co-occurring mental disordersoccurring mental disorders

• Review risk-need-responsivity, cognitive-behavioral, Review risk-need-responsivity, cognitive-behavioral, and social learning approaches for treating offenders and social learning approaches for treating offenders who have behavioral health disorderswho have behavioral health disorders

• Identify practice implications of using these Identify practice implications of using these approaches with offendersapproaches with offenders

Resources

• NDCI/NADCP http://www.ndci.org/NDCI/NADCP http://www.ndci.org/

• SAMHSA’s GAINS Center SAMHSA’s GAINS Center http://gainscenter.samhsa.gov/http://gainscenter.samhsa.gov/

• CSAT TIP #42 and #44 CSAT TIP #42 and #44 http://www.ncbi.nlm.nih.gov/books/NBKhttp://www.ncbi.nlm.nih.gov/books/NBK82999/82999/

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

Resources

• SAMHSA/CMHS Toolkit on Integrated SAMHSA/CMHS Toolkit on Integrated Treatment for Co-Occurring Disorders Treatment for Co-Occurring Disorders http://store.samhsa.gov/product/Integratedhttp://store.samhsa.gov/product/Integrated-Treatment-for-Co-Occurring-Disorders--Treatment-for-Co-Occurring-Disorders-Evidence-Based-Practices-EBP-KIT/Evidence-Based-Practices-EBP-KIT/SMA08-4367SMA08-4367

• National Institute on Drug Abuse (NIDA) National Institute on Drug Abuse (NIDA) http://www.drugabuse.gov/http://www.drugabuse.gov/

What Doesn’t Work in Offender Treatment?

Incarceration without treatmentIncarceration without treatment Supervision without intensive treatmentSupervision without intensive treatment Self-help without intensive treatmentSelf-help without intensive treatment Drug educationDrug education FilmsFilms Building self-esteem as primary focusBuilding self-esteem as primary focus Targeting participants with low criminal risk or Targeting participants with low criminal risk or

with mild substance use disorderswith mild substance use disorders Mixing high risk and low risk participantsMixing high risk and low risk participants Non-manualized treatmentNon-manualized treatment

Evidence-Based Models for

Offender Treatment

Evidence-Based Models to Guide Offender Treatment

• Integrated Dual Diagnosis Treatment (IDDT)Integrated Dual Diagnosis Treatment (IDDT)

• Risk-Need-Responsivity (RNR) Model Risk-Need-Responsivity (RNR) Model

• Cognitive-Behavioral Treatment (CBT)Cognitive-Behavioral Treatment (CBT)

• Social Learning ModelSocial Learning Model

• Combining several models produces larger Combining several models produces larger reductions in recidivism (26-30%; Dowden & reductions in recidivism (26-30%; Dowden & Andrews, 2004)Andrews, 2004)

Common Features of CBT and Social Learning Models• Focus on skill-building (e.g., coping strategies)Focus on skill-building (e.g., coping strategies)

• Use of role play, modeling, feedbackUse of role play, modeling, feedback

• Repetition of material, rehearsal of skillsRepetition of material, rehearsal of skills

• Behavior modificationBehavior modification

• Interpersonal problem-solvingInterpersonal problem-solving

• Cognitive strategies used to address ‘criminal Cognitive strategies used to address ‘criminal thinking’thinking’

Using Risk and Needs to Guide Offender Treatment

• Focus resources on Focus resources on Moderate to High Risk Moderate to High Risk cases cases ((risk for criminal recidivismrisk for criminal recidivism))

• Interventions should target Interventions should target Dynamic Risk Factors Dynamic Risk Factors for criminal recidivism (e.g., antisocial attitudes, for criminal recidivism (e.g., antisocial attitudes, criminal peers, substance abuse)criminal peers, substance abuse)

• Focus on those who have Focus on those who have High Needs High Needs for for substance abuse treatment substance abuse treatment

• Providing intensive treatment and supervision for Providing intensive treatment and supervision for low risk drug offenders can low risk drug offenders can increase recidivism increase recidivism

• Mixing risk levels Mixing risk levels is contraindicatedis contraindicated

Dynamic Risk Factors for Criminal Recidivism

1. Antisocial attitudes2. Antisocial friends and peers3. Antisocial personality pattern

4. Substance abuse

5. Family and/or marital problems

6. Lack of education7. Poor employment history8. Lack of prosocial leisure

activities

11

Responsivity

Strategies to Strategies to tailor treatment and supervisiontailor treatment and supervision to to help offenders engage in evidence-based help offenders engage in evidence-based interventions that address dynamic risk factorsinterventions that address dynamic risk factors

• Mental health treatmentMental health treatment• Trauma/PTSD services, gender-specific treatmentTrauma/PTSD services, gender-specific treatment• Motivational enhancement techniquesMotivational enhancement techniques• Address language and literacy issuesAddress language and literacy issues• Use of cognitive-behavioral approachesUse of cognitive-behavioral approaches

How is Level of Risk Determined?

• Risk for Risk for criminal recidivismcriminal recidivism• Use of Use of risk assessmentrisk assessment

- ‘Static’ factors (e.g., criminal history)- ‘Static’ factors (e.g., criminal history)

- ‘Dynamic’or changeable factors that are targets of - ‘Dynamic’or changeable factors that are targets of

interventions in the criminal justice system interventions in the criminal justice system

Risk Assessment Instruments

Integrating Treatment and Supervision Reduces Risk

National Reentry Resource Center, 2012

Evidence-Based Screening and

Assessment

Importance of Screening and Assessment for CODs

High prevalenceHigh prevalence rates of behavioral health rates of behavioral health and related disorders in justice settingsand related disorders in justice settings

Persons with undetected disorders are likely Persons with undetected disorders are likely to to cycle back throughcycle back through the justice system the justice system

Allows for Allows for treatment planningtreatment planning and linking and linking to appropriate treatment servicesto appropriate treatment services

Offender programs using comprehensive Offender programs using comprehensive assessment have assessment have better outcomesbetter outcomes

Key Screening Domains for Co-Occurring Disorders

• Mental disordersMental disorders• Substance use disordersSubstance use disorders• Trauma/PTSDTrauma/PTSD• Suicide riskSuicide risk• MotivationMotivation• Criminal risk levelCriminal risk level

• All offenders should be screened All offenders should be screened for trauma for trauma history; rates of trauma > 75% among female history; rates of trauma > 75% among female offenders and > 50% among male offendersoffenders and > 50% among male offenders

• The initial screen does not have to be conducted by The initial screen does not have to be conducted by a licensed cliniciana licensed clinician

• Many Many non-proprietary screens non-proprietary screens are availableare available

• Positive screens should be referred for Positive screens should be referred for more more comprehensive assessment comprehensive assessment

Screening for Trauma and PTSD

Trauma and PTSD Screening Issues

• PTSD and trauma are often overlooked PTSD and trauma are often overlooked in screeningin screening

• Other diagnoses are used to explain Other diagnoses are used to explain symptomssymptoms

• Result - lack of specialized treatment, Result - lack of specialized treatment, symptoms masked, poor outcomessymptoms masked, poor outcomes

Evidence-Based Offender

Treatment for SUDs and CODs

Evidence-Based Treatment Interventions for Offenders

• Integrated MH and SA treatmentIntegrated MH and SA treatment• Cognitive-behavioral treatmentsCognitive-behavioral treatments• Relapse prevention Relapse prevention • Motivational interventions (MI/MET)Motivational interventions (MI/MET)• Contingency managementContingency management• Behavioral skills trainingBehavioral skills training• MedicationsMedications (for both disorders) (for both disorders)• Trauma-focused treatmentTrauma-focused treatment• Family interventions Family interventions (psychoeducational)(psychoeducational)

Drug Courts

• Meta-analysesMeta-analyses indicate that indicate that drug courts lead to drug courts lead to reductions in recidivism from 8-26% reductions in recidivism from 8-26% vs. comparisonsvs. comparisons-- Drug court effects on recidivism Drug court effects on recidivism extend to at extend to at least 36 months least 36 months (Mitchell et al., 2012)(Mitchell et al., 2012)-- Wide variation in effect size; 15% of programs Wide variation in effect size; 15% of programs ineffectiveineffective

• Drug courts produce Drug courts produce cost benefits cost benefits of of $4,767 - $5,680$4,767 - $5,680 per per participant (Aos et al., 2006; Rossman et al., 2011) participant (Aos et al., 2006; Rossman et al., 2011)

0

10

20

30

40

50

MH

33%

TC only

16%

5%

TC +after-care

Total n=139 n=64 n=32 n=43

Prison Treatment and Reentry

Sacks et al. 2004

31Kelly, Finney, & Moos, 2005

Effectiveness of Outpatient Treatment with Offenders

• Outpatient treatment of probationers leads to Outpatient treatment of probationers leads to fewer arrests fewer arrests at 12 and 24 month follow-up at 12 and 24 month follow-up (Lattimore et al., 2005) vs. untreated (Lattimore et al., 2005) vs. untreated probationersprobationers

• High-risk probationers in outpatient treatment High-risk probationers in outpatient treatment experience 10-20% experience 10-20% reductions in recidivism reductions in recidivism (Petersilia & Turner, 1990, 1993)(Petersilia & Turner, 1990, 1993)

• Reductions in recidivism Reductions in recidivism durable for 72 durable for 72 monthsmonths after treatment (Krebs et al., 2009) after treatment (Krebs et al., 2009)

Optimal Duration of Outpatient Treatment

• At least 3 months At least 3 months of outpatient treatment neededof outpatient treatment needed• Greatest effects for outpatient treatment of Greatest effects for outpatient treatment of 6-12 6-12

months months • Diminishing outcomes Diminishing outcomes for treatment lasting > 1 year for treatment lasting > 1 year • Best outcomes for Best outcomes for persons completing treatmentpersons completing treatment

Outpatient vs. Residential Treatment

• BothBoth outpatient and residential treatment are outpatient and residential treatment are effective for offenderseffective for offenders

• Outpatient treatment is more effective Outpatient treatment is more effective than than residential treatment for drug-involved probationers residential treatment for drug-involved probationers (Krebs et al., 2009) and during reentry (Burdon et (Krebs et al., 2009) and during reentry (Burdon et al., 2004)al., 2004)

• Cost-benefit analysisCost-benefit analysis• Greater benefits for outpatient treatment in non-offender Greater benefits for outpatient treatment in non-offender

samples (e.g., CALDATA, French et al., 2000, 2002)samples (e.g., CALDATA, French et al., 2000, 2002)• Excellent benefit-cost ratio for intensive supervision + Excellent benefit-cost ratio for intensive supervision +

treatment, community TC, community outpatient, and treatment, community TC, community outpatient, and drug court programs (Aos et al., 2001; Drake et al., 2009)drug court programs (Aos et al., 2001; Drake et al., 2009)

Aftercare/Continuing Care

• Aftercare services among drug-involved offenders can Aftercare services among drug-involved offenders can significantly reduce substance use and rearrest significantly reduce substance use and rearrest (Butzin et al., 2006)(Butzin et al., 2006)

• Outpatient aftercare services can reduce likelihood of Outpatient aftercare services can reduce likelihood of reincarceration by 63% (Burdon et al., 2004)reincarceration by 63% (Burdon et al., 2004)

• Aftercare services provide $4.4 - $9 return for every Aftercare services provide $4.4 - $9 return for every dollar invested (Roman & Chalfin, 2006)dollar invested (Roman & Chalfin, 2006)

• Promising interventions Promising interventions for high risk/high need for high risk/high need offendersoffenders• Recovery management checkups (Rush et al., 2008)Recovery management checkups (Rush et al., 2008)• Critical time intervention (Kasprow & Rosenheck, Critical time intervention (Kasprow & Rosenheck,

2007)2007)

Adaptations for COD Treatment

• Destigmatize mental illnessDestigmatize mental illness• Focus on symptom management vs. cureFocus on symptom management vs. cure• Focus on education/support vs. compliance/sanctionsFocus on education/support vs. compliance/sanctions• Higher staff-to-participant ratio, more structureHigher staff-to-participant ratio, more structure• Dually credentialed staffDually credentialed staff• Increased length of services ( > 1 year)Increased length of services ( > 1 year)• Pace of treatment slowerPace of treatment slower• Motivational interventionsMotivational interventions• Cognitive and memory enhancement strategiesCognitive and memory enhancement strategies• Focus on housing, employment, medication needsFocus on housing, employment, medication needs

Evidence-Based Integrated COD Treatment Curricula

• Illness Management and Recovery (IMR)Illness Management and Recovery (IMR)• Integrated Group Therapy for Bipolar Integrated Group Therapy for Bipolar

Disorder and Substance AbuseDisorder and Substance Abuse• Integrated Cognitive-Behavior Therapy Integrated Cognitive-Behavior Therapy

(ICBT)(ICBT)• Seeking Safety (SA and trauma/PTSD)Seeking Safety (SA and trauma/PTSD)

Structural COD Interventions• Assertive Community Treatment (ACT)Assertive Community Treatment (ACT)• Residential Treatment (Therapeutic Residential Treatment (Therapeutic

Communities; TCs) modified for CODsCommunities; TCs) modified for CODs- More flexibilityMore flexibility- Less confrontationLess confrontation- Greater individualization of servicesGreater individualization of services- More staff involvementMore staff involvement- Longer durationLonger duration• Case management and legal coercion – assist in Case management and legal coercion – assist in

treatment retentiontreatment retention• Supported housingSupported housing

Specialized Supervision Caseloads

• Specialized MH/COD caseloadsSpecialized MH/COD caseloads• Smaller caseloads with more intensive services (e.g., Smaller caseloads with more intensive services (e.g.,

< 45)< 45)• Sustained and specialized officer trainingSustained and specialized officer training• Dual focus on treatment and surveillanceDual focus on treatment and surveillance• Active engagement in Active engagement in SA and MH servicesSA and MH services