1. Roger H. Peters, Ph.D., University of South Florida; rhp@usf.edu Co-Occurring Disorders 102

2. Goals of this Presentation Review: Available screening instrumentsAvailable screening instruments Conceptual model to drive COD services (Risk-Need-Responsivity)Conceptual model to drive COD services (Risk-Need-Responsivity) Treatment modifications for CODsTreatment modifications for CODs Special populations and CODsSpecial populations and CODs 2

3. 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 3

4. Survey Results: Offender Screening Wide variation in types of SA screening instruments administered Wide variation in types of SA screening instruments administered 32% of sites used no SA screening instruments 32% of sites used no SA screening instruments 42% of sites did not use a standardized SA screening instrument (Taxman et al., 2007) 42% of sites did not use a standardized SA screening instrument (Taxman et al., 2007) 4

5. Screening for CODs Routine screening for both sets of disordersRoutine screening for both sets of disorders Criminal risk levelCriminal risk level Acute MH and SA symptoms:Acute MH and SA symptoms: Suicidal thoughts and behaviorSuicidal thoughts and behavior Depression, hallucinations, delusionsDepression, hallucinations, delusions Potential for drug/alcohol withdrawalPotential for drug/alcohol withdrawal History of MH treatment including use of medsHistory of MH treatment including use of meds Determine need/urgency for referralDetermine need/urgency for referral

6. Screening—Mental Health Brief Jail Mental Health ScreenBrief Jail Mental Health Screen Mental Health Screening Form–IIIMental Health Screening Form–III MINI–MMINI–M CODSI (Sacks et al, 2007)CODSI (Sacks et al, 2007) GAIN–SSGAIN–SS 6

7. Screening—Substance Abuse Simple Screening InstrumentSimple Screening Instrument TCU Drug Screen–IITCU Drug Screen–II ASI–Alcohol and Drug Abuse sectionsASI–Alcohol and Drug Abuse sections GAIN–SSGAIN–SS 7

8. Screening—Trauma and PTSD Clinician-Administered PTSD Scale for DSM-IVClinician-Administered PTSD Scale for DSM-IV Impact of Events ScaleImpact of Events Scale Primary Care PTSD ScreenPrimary Care PTSD Screen PTSD Checklist–Civilian VersionPTSD Checklist–Civilian Version Trauma Symptom InventoryTrauma Symptom Inventory 8

9. Specialized Screens BASIS-24BASIS-24 Centre for Addiction and Mental Health Concurrent Disorders Screener (CAMH- CDS)Centre for Addiction and Mental Health Concurrent Disorders Screener (CAMH- CDS) Psychiatric Diagnostic Screening Questionnaire (PDSQ)Psychiatric Diagnostic Screening Questionnaire (PDSQ) 9

10. Instruments for Adolescents CAFASCAFAS GAINGAIN MAYSI-2MAYSI-2 PESQPESQ POSITPOSIT 10

11. Other Screening Domains MotivationMotivation Offender Risk and NeedsOffender Risk and Needs Trauma and PTSDTrauma and PTSD 11

12. Instruments—Motivation and Stages of Change CMRSCMRS RCQRCQ SOCRATESSOCRATES TCU Treatment Motivation ScalesTCU Treatment Motivation Scales URICAURICA 12

13. Instruments—Offender Risk and Needs HCR-20HCR-20 LCSFLCSF LSI-RLSI-R PCL-SVPCL-SV RANTRANT STARTSTART 13

14. Trauma and Victimization Female offenders frequently have been victims of physical or sexual violenceFemale offenders frequently have been victims of physical or sexual violence Trauma history—should be expectation for women in CJ settingsTrauma history—should be expectation for women in CJ settings Impact of violence is widespread, can impair recovery from MH and SA disordersImpact of violence is widespread, can impair recovery from MH and SA disorders

15. 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

16. Screening for Trauma and PTSD All women should be screened for trauma history across different justice settingsAll 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 detailsInitial 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 availableMany simple, non-proprietary screening instruments available Positive screens should be referred for more comprehensive assessmentPositive screens should be referred for more comprehensive assessment 16

17. Screening Instruments for Trauma and PTSD Clinician-Administered PTSD Scale for DSM-IV (CAPS)Clinician-Administered PTSD Scale for DSM-IV (CAPS) Impact of Events Scale (IES)Impact of Events Scale (IES) Primary Care PTSD Screen (PC-PTSD)Primary Care PTSD Screen (PC-PTSD) PTSD Checklist—Civilian Version (PCL- C)PTSD Checklist—Civilian Version (PCL- C) Trauma Symptom Inventory (TSI)Trauma Symptom Inventory (TSI) 17

18. Admission Criteria and CODs Excluding persons with CODs is NOT a viable optionExcluding persons with CODs is NOT a viable option How to determine eligibility for services?How to determine eligibility for services? Triage to specialized COD servicesTriage to specialized COD services Target moderate to high criminal risk levelsTarget moderate to high criminal risk levels

19. Assessing Program Eligibility 1.Review existing program resources to work with co-occurring disorders 1.Review existing program resources to work with co-occurring disorders  Staff with MH and SA treatment experience  Linkages with institutional and community- based MH and SA services  Specialized “tracks,” groups, or other services for co-occurring disorders  Psychiatric/medication consultation 19

20. Assessing Program Eligibility 2. Determine functioning level required for 2. Determine functioning level required for program participation program participation Treatment groups Treatment groups Therapeutic communities Therapeutic communities Community supervision Community supervision Employment and peer support programs Employment and peer support programs 20

21. Assessing Program Eligibility 3. Examine broad categories of functioning 3. Examine broad categories of functioning Cognitive functioning Cognitive functioning Major mental health symptoms Major mental health symptoms Unusual behaviors Unusual behaviors Ability to interact with staff and participants (e.g., group settings) Ability to interact with staff and participants (e.g., group settings) How responds to stress How responds to stress Reading, language abilities Reading, language abilities 21

22. Key Assessment Information Scope and severity of MH and SA disordersScope and severity of MH and SA disorders Pattern of interaction between the disordersPattern of interaction between the disorders Conditions associated with occurrence and maintenance of the disordersConditions associated with occurrence and maintenance of the disorders Criminal-antisocial beliefsCriminal-antisocial beliefs Motivation for treatmentMotivation for treatment Family and social relationshipsFamily and social relationships Physical health status and medical historyPhysical health status and medical history 22

23. 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 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 Supervision Caseload Higher Risk Populations Greater criminogenic needs CODs Specialized Treatments  Illness Management & Recovery (IMR), Integrated Group Therapy (IGT)  Seeking Safety

24. Risk-Need-Responsivity (RNR) The RISK principle tell us WHO to targetThe RISK principle tell us WHO to target The NEED principle tells us WHAT to targetThe NEED principle tells us WHAT to target The RESPONSIVITY principle tells us HOW to targetThe RESPONSIVITY principle tells us HOW to target

25. “Risk” Principle Goal is to match the level of services to the offender’s likelihood to re-offendGoal is to match the level of services to the offender’s likelihood to re-offend Provides guidance re. WHO to target for program interventionsProvides guidance re. WHO to target for program interventions Adjust interventions, structure, and supervision by risk levelAdjust interventions, structure, and supervision by risk level

26. “Need” Principle Assess criminogenic needs and address these needs through focused interventionsAssess criminogenic needs and address these needs through focused interventions Place higher-risk/higher-need offenders in treatment servicesPlace higher-risk/higher-need offenders in treatment services Prioritize a person’s “high” needs in coordinating servicesPrioritize a person’s “high” needs in coordinating services

27. 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)

28. Criminogenic Needs—“Big 8” 1. 1.Antisocial attitudes 2. 2.Antisocial friends and peers 3. 3.Antisocial personality pattern 4. 4.Substance abuse 5. 5.Family and/or marital factors 6. 6.Lack of education 7. 7.Poor employment history 8. 8.Lack of prosocial leisure activities

29. Interventions Cognitive skills to address ‘criminal thinking’, positive peer supports, problem- solving skills Interventions Substance abuse treatment Co-occurring disorders treatment Job training/employment readiness

30. “Responsivity” Principle Optimizing offenders’ engagement, learning, and skill-buildingOptimizing offenders’ engagement, learning, and skill-building Allows offenders to respond effectively to interventionsAllows offenders to respond effectively to interventions

31. Responsivity— general strategies General approaches for providing interventions for offenders with CODsGeneral approaches for providing interventions for offenders with CODs -Cognitive-behavioral -Social learning

32. Responsivity— fine tuning Fine tuning interventions based on: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

33. Key Features of COD Treatment Programs  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 problem- solving skills 33

34. Structural Features of Offender Treatment Programs  Therapeutic communities  Isolated treatment units  Program phases  Blending of MH and SA services  Assessment  Specialized mental health services  Transition and reentry services 34

35. Stage-Specific Treatment People with CODs who have had contact with the CJ system come to treatment with varying degrees of readiness and motivationPeople 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 planningAssessment of individuals’ stages of change is valuable in treatment planning Allows development of stage-specific treatment for co-occurring disordersAllows development of stage-specific treatment for co-occurring disorders Interventions are more likely to address goals that are valued by the individualInterventions are more likely to address goals that are valued by the individual 35

36. COD Program Phases  Orientation  Intensive treatment  Relapse prevention/transition 36

37. Orientation Phase Comprehensive assessmentComprehensive assessment Persuasion and engagement groupsPersuasion and engagement groups Treatment plan or contractTreatment plan or contract Introduction to recovery processIntroduction to recovery process 37

38. Intensive Treatment Phase Individual and group treatmentIndividual and group treatment Broad array of cognitive-behavioral interventionsBroad array of cognitive-behavioral interventions Specialized dual diagnosis interventionsSpecialized dual diagnosis interventions 38

39. Relapse Prevention/ Transition Phase Education about the relapse processEducation about the relapse process Relapse prevention planRelapse prevention plan Transition planTransition plan Case managers or transition coordinatorsCase managers or transition coordinators 39

40. Treatment Modifications Longer duration of treatment Longer duration of treatment More extensive assessment More extensive assessment Emphasis on psychoeducational and supportive approaches Emphasis on psychoeducational and supportive approaches Higher staff ratio, more MH staff Higher staff ratio, more MH staff 40

41. 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 41

42. Modifying Treatment for Cognitive Impairment Minimize need for abstraction (e.g., use concrete, specific scenarios)Minimize need for abstraction (e.g., use concrete, specific scenarios) Have demonstrate skillsHave demonstrate skills Keep instructions briefKeep instructions brief Use audiovisual aidsUse audiovisual aids Keep role plays short and focused (Bellack, 2003)Keep role plays short and focused (Bellack, 2003) 42

43. Treating Female Offenders with CODs Focus on trauma and spousal abuseFocus on trauma and spousal abuse Emphasis on education and job trainingEmphasis on education and job training Parenting skillsParenting skills Female role models and peer supportFemale role models and peer support Assertive outreach and crisis interventionAssertive outreach and crisis intervention 43

44. Treatments for Trauma and Substance Abuse Seeking Safety (Najavits, 2002)Seeking Safety (Najavits, 2002) Trauma Recovery and Empowerment (TREM) (Harris, 1998)Trauma Recovery and Empowerment (TREM) (Harris, 1998) Treating concurrent PTSD and cocaine dependence (Brady et al., 2001)Treating concurrent PTSD and cocaine dependence (Brady et al., 2001) Substance Dependence Posttraumatic Stress Disorder Therapy (Triffleman, et al., 1999)Substance Dependence Posttraumatic Stress Disorder Therapy (Triffleman, et al., 1999) 44

45. Key Transition Services Development of re-entry or transition planDevelopment of re-entry or transition plan Assistance to engage in community-based SA and MH treatmentAssistance to engage in community-based SA and MH treatment Engagement in peer support and self-help networks to assist in recoveryEngagement in peer support and self-help networks to assist in recovery Stable housingStable housing Vocational training and employment supportVocational training and employment support Case management and community supervisionCase management and community supervision 45

46. The APIC Model Assess clinical and social needs and risk levelAssess clinical and social needs and risk level Plan for treatment and servicesPlan for treatment and services Identify required community programsIdentify required community programs Coordinate the transition plan services (Osher, Steadman, & Barr, 2002)Coordinate the transition plan services (Osher, Steadman, & Barr, 2002) 46

47. APIC Reentry Checklist: Primary Domains ♦ Mental health services ♦ Psychotropic medications ♦ Housing ♦ Substance abuse services ♦ Health care/benefits ♦ Income/benefits ♦ Food/clothing ♦ Transportation ♦ Other 47

48. 48 MH 33% TC only 16% 5% TC + after- care Total n=139 n=64 n=32 n=43 Sacks et al. 2004 Effectiveness of Prison COD Treatment and Reentry—1 Year Reincarceration

49. Court Hearings and Judicial Monitoring More frequent court hearings may be neededMore frequent court hearings may be needed Hearings provide a good opportunity to recognize and reward positive behavioral changeHearings provide a good opportunity to recognize and reward positive behavioral change Specialized docketsSpecialized dockets - Less formal, smaller, more private - More frequent - Greater interaction between judge and participants - Include mental health professionals

50. Community Supervision Active involvement in court and community treatment teams, in-reach to jail and prisonActive involvement in court and community treatment teams, in-reach to jail and prison Rapid crisis response capabilityRapid crisis response capability Monitor medication compliance (MH agencies)Monitor medication compliance (MH agencies) Home visits usefulHome visits useful “Fugitive” warrants receive priority“Fugitive” warrants receive priority Taper supervision over timeTaper supervision over time

51. Specialized 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

52. Specialized Caseloads Relationship quality important (trust, caring- fairness, avoid punitive stance)—“firm but fair”Relationship quality important (trust, caring- fairness, avoid punitive stance)—“firm but fair” Problem-solving approach vs. reliance on sanctionsProblem-solving approach vs. reliance on sanctions Wide range of incentives and sanctionsWide range of incentives and sanctions Flexibly apply sanctionsFlexibly apply sanctions Avoid sanctions that remove participants from treatmentAvoid sanctions that remove participants from treatment Higher revocation thresholdHigher revocation threshold Improved outcomes—lower rates of revocation, arrest, and incarceration (Skeem et al., 2009)Improved outcomes—lower rates of revocation, arrest, and incarceration (Skeem et al., 2009)