1. 2014 FADAA/FCCMH Annual Conference Orlando, Florida; August 6, 2014 Roger H. Peters, Ph.D., University of South Florida rhp@usf.edu 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 disordersEvidence-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 disordersReview 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 offendersIdentify practice implications of using these approaches with offenders

3. Resources NDCI/NADCP http://www.ndci.org/NDCI/NADCP http://www.ndci.org/http://www.ndci.org/ SAMHSA’s GAINS Center http://gainscenter.samhsa.gov/SAMHSA’s GAINS Center http://gainscenter.samhsa.gov/ http://gainscenter.samhsa.gov/ CSAT TIP #42 and #44 http://www.ncbi.nlm.nih.gov/books/NBK8 2999/CSAT TIP #42 and #44 http://www.ncbi.nlm.nih.gov/books/NBK8 2999/ http://www.ncbi.nlm.nih.gov/books/NBK8 2999/ http://www.ncbi.nlm.nih.gov/books/NBK8 2999/ Council of State Governments - Justice Center http://csgjusticecenter.org/Council of State Governments - Justice Center http://csgjusticecenter.org/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/SMA08-4367SAMHSA/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 http://store.samhsa.gov/product/Integrated -Treatment-for-Co-Occurring-Disorders- Evidence-Based-Practices-EBP- KIT/SMA08-4367 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/National Institute on Drug Abuse (NIDA) http://www.drugabuse.gov/ 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)Integrated Dual Diagnosis Treatment (IDDT) Risk-Need-Responsivity (RNR) ModelRisk-Need-Responsivity (RNR) Model Cognitive-Behavioral Treatment (CBT)Cognitive-Behavioral Treatment (CBT) Social Learning ModelSocial Learning Model Combining several models produces larger reductions in recidivism (26-30%; Dowden & Andrews, 2004)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)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 thinking’Cognitive strategies used to address ‘criminal thinking’

9. Using Risk and Needs to Guide Offender Treatment Focus resources on Moderate to High Risk cases (risk for criminal recidivism) 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) 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 Focus on those who have High Needs for substance abuse treatment Providing intensive treatment and supervision for low risk drug offenders can increase recidivism Providing intensive treatment and supervision for low risk drug offenders can increase recidivism Mixing risk levels is contraindicated Mixing risk levels is contraindicated

10. Dynamic Risk Factors for Criminal Recidivism 1.Antisocial attitudes 2.Antisocial friends and peers 3.Antisocial personality pattern 4.Substance abuse 5.Family and/or marital problems 6.Lack of education 7.Poor employment history 8.Lack of prosocial leisure activities

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

13. How is Level of Risk Determined ? Risk for criminal recidivism Risk for criminal recidivism Use of risk assessment Use of risk 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

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 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 Persons with undetected disorders are likely to cycle back through the justice system Allows for treatment planning and linking to appropriate treatment services Allows for treatment planning and linking to appropriate treatment services Offender programs using comprehensive assessment have better outcomes Offender programs using comprehensive assessment have better outcomes

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

22. All offenders should be screened for trauma history; rates of trauma > 75% among female offenders and > 50% among male offendersAll 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 clinicianThe initial screen does not have to be conducted by a licensed clinician Many non-proprietary screens are availableMany non-proprietary screens are available Positive screens should be referred for more comprehensive assessmentPositive screens should be referred for more comprehensive assessment Screening for Trauma and PTSD

23. Trauma and PTSD Screening Issues PTSD and trauma are often overlooked in screeningPTSD and trauma are often overlooked in screening Other diagnoses are used to explain symptomsOther diagnoses are used to explain symptoms Result - lack of specialized treatment, symptoms masked, poor outcomesResult - 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 Integrated MH and SA treatment Cognitive-behavioral treatments Cognitive-behavioral treatments Relapse prevention Relapse prevention Motivational interventions (MI/MET) Motivational interventions (MI/MET) Contingency management Contingency management Behavioral skills training Behavioral skills training Medications (for both disorders) Medications (for both disorders) Trauma-focused treatment Trauma-focused treatment Family interventions (psychoeducational)Family interventions (psychoeducational)

28. Drug Courts Meta-analyses indicate that drug courts lead to reductions in recidivism from 8-26% vs. comparisonsMeta-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)Drug courts produce cost benefits of $4,767 - $5,680 per participant (Aos et al., 2006; Rossman et al., 2011)

29. 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

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 probationersOutpatient 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)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)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 neededAt least 3 months of outpatient treatment needed Greatest effects for outpatient treatment of 6-12 monthsGreatest effects for outpatient treatment of 6-12 months Diminishing outcomes for treatment lasting > 1 yearDiminishing outcomes for treatment lasting > 1 year Best outcomes for persons completing treatmentBest outcomes for persons completing treatment

33. Outpatient vs. Residential Treatment Both outpatient and residential treatment are effective for offendersBoth 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)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 analysisCost-benefit analysis Greater benefits for outpatient treatment in non-offender samples (e.g., CALDATA, French et al., 2000, 2002)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)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)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)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)Aftercare services provide $4.4 - $9 return for every dollar invested (Roman & Chalfin, 2006) Promising interventions for high risk/high need offendersPromising interventions for high risk/high need offenders Recovery management checkups (Rush et al., 2008)Recovery management checkups (Rush et al., 2008) Critical time intervention (Kasprow & Rosenheck, 2007)Critical time intervention (Kasprow & Rosenheck, 2007)

35. Adaptations for COD Treatment Destigmatize mental illness Destigmatize mental illness Focus on symptom management vs. cure Focus 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

36. Evidence-Based Integrated COD Treatment Curricula Illness Management and Recovery (IMR)Illness Management and Recovery (IMR) Integrated Group Therapy for Bipolar Disorder and Substance AbuseIntegrated Group Therapy for Bipolar Disorder and Substance Abuse Integrated Cognitive-Behavior Therapy (ICBT)Integrated Cognitive-Behavior Therapy (ICBT) Seeking Safety (SA and trauma/PTSD)Seeking Safety (SA and trauma/PTSD)

37. Structural COD Interventions Assertive Community Treatment (ACT)Assertive Community Treatment (ACT) Residential Treatment (Therapeutic Communities; TCs) modified for CODsResidential 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 retentionCase management and legal coercion – assist in treatment retention Supported housingSupported housing

38. Specialized Supervision Caseloads Specialized MH/COD caseloadsSpecialized MH/COD caseloads Smaller caseloads with more intensive services (e.g., < 45)Smaller caseloads with more intensive services (e.g., < 45) Sustained and specialized officer trainingSustained and specialized officer training Dual focus on treatment and surveillanceDual focus on treatment and surveillance Active engagement in SA and MH servicesActive engagement in SA and MH services