1. 1 Court-Based Interventions and Co-Occurring Disorders Florida Partners in Crisis 2012 Annual Conference and Justice Institute Orlando, Florida, July 13, 2012 Presented by Roger H. Peters, Ph.D., University of South Florida, and Fred C. Osher, M.D., Council of State Governments Justice Center

2. 2 Workshop Outline I. Overview of workshop II. Integrated screening and assessment III. Modifications to court program structure and treatment IV. Clinical Considerations: Principles of care for CODs V. Linking to EBP’s in the community VI. Q & A

3. (GAINS Center, 2004; Steadman et al., 2009)

4. 4 Co-Occurring Substance Use Disorders 74% of state prisoners with mental problems also have substance abuse or dependence problems (U.S. Department of Justice, 2006)

5. 5 Persons with CODs Repeatedly cycle through the criminal justice and treatment systems Repeatedly cycle through the criminal justice and treatment systems Experience problems when not taking medications, not in treatment, experiencing mental health symptoms, using alcohol or drugs Experience problems when not taking medications, not in treatment, experiencing mental health symptoms, using alcohol or drugs Small amounts of alcohol or drugs may trigger recurrence of mental health symptoms Small amounts of alcohol or drugs may trigger recurrence of mental health symptoms Antisocial beliefs similar to other offenders Antisocial beliefs similar to other offenders More criminal risk factors than other offenders More criminal risk factors than other offenders

6. Conceptual Model of COD Treatment Services in Specialty Courts Select High Risk Population Co-occurring disorders Higher levels of risk and need Optimize the Treatment Process Matching to treatment and supervision (by risk and need) Address special needs Continuing care (post-graduation) COD Treatment Integrated treatment services Cognitive-behavioral treatment Medications Contingency management MET/motivational interventions Relapse prevention Specialized Supervision Judicial hearings Community supervision Blended Screening and Assessment Strategies 6

7. Integrated Screening and Assessment Routine screening for both sets of disordersRoutine screening for both sets of disorders Identify acute symptomsIdentify acute symptoms Focus on areas of functional impairment that would prevent effective drug court participationFocus on areas of functional impairment that would prevent effective drug court participation Examine longitudinal interaction of disordersExamine longitudinal interaction of disorders Assess participant motivationAssess participant motivation

8. Mental Health Screening Instruments Brief Jail Mental Health Screen Mental Health Screening Form-III MINI- Screen Global Appraisal of Need (GAIN-SS) 8

9. 9 Substance Use Screening Instruments Global Appraisal of Need (GAIN-SS) ASI- Alcohol and Drug Abuse sections Simple Screening instrument (SSI) TCU Drug Screen - II

10. 10 Features of COD Treatment Highly structured treatment servicesHighly structured treatment services Destigmatize mental illnessDestigmatize mental illness Focus on symptom management vs. cureFocus on symptom management vs. cure Education regarding individual diagnoses and interactive effects of CODsEducation regarding individual diagnoses and interactive effects of CODs “Criminal thinking” groups“Criminal thinking” groups Basic life management and problem-solving skillsBasic life management and problem-solving skills

11. 11 COD Program Phases Orientation Orientation Relapse prevention/transition Relapse prevention/transition Intensive treatment Intensive treatment

12. Treatment Modifications - I Higher staff-to-participant ratioHigher staff-to-participant ratio Increased length of services:Increased length of services: Pace of treatment slowerPace of treatment slower Flexible progression through treatment allowedFlexible progression through treatment allowed Ongoing tracking and case monitoringOngoing tracking and case monitoring Extended exit and re-entry policiesExtended exit and re-entry policies Treatment may last for more than one yearTreatment may last for more than one year

13. Treatment Modifications - II Integrated treatment to address MH and SA issuesIntegrated treatment to address MH and SA issues More emphasis on education and support rather than compliance and sanctionsMore emphasis on education and support rather than compliance and sanctions Motivational interventions in both group and individual settingsMotivational interventions in both group and individual settings Cognitive and memory enhancement strategiesCognitive and memory enhancement strategies Case management and outreach servicesCase management and outreach services Focus on housing, employment, medication needsFocus on housing, employment, medication needs

14. 14 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 skills Have demonstrate skills Keep instructions brief Keep instructions brief Use audiovisual aids Use audiovisual aids Keep role plays short and focused (Bellack, 2003) Keep role plays short and focused (Bellack, 2003)

15. Program Modifications for CODs Supplementary services (COD treatment groups, medication clinic, case management/crisis intervention)Supplementary services (COD treatment groups, medication clinic, case management/crisis intervention) Tracks within specialty court programsTracks within specialty court programs COD docketsCOD dockets Transfer between drug courts, mental health courts, COD docketsTransfer between drug courts, mental health courts, COD dockets Extended program duration (e.g., 18 mos.)Extended program duration (e.g., 18 mos.) Blended screening and assessmentBlended screening and assessment Specialized supervision teamsSpecialized supervision teams 15

16. 16 Community partnerships for COD/MH servicesCommunity partnerships for COD/MH services Recovery-oriented treatment planning and case managementRecovery-oriented treatment planning and case management Dually credentialed staffDually credentialed staff Focus on incentives and non-punitive sanctionsFocus on incentives and non-punitive sanctions Specialized supervision teamsSpecialized supervision teams Other Modifications for CODs

17. Modifying Court Hearings 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 Less formal, smaller, more privateLess formal, smaller, more private Greater interaction between judge and participantsGreater interaction between judge and participants Include mental health professionalsInclude mental health professionals

18. 18 Community Supervision and CODs Specialized caseloadsSpecialized caseloads (MH/COD) Smaller caseloads (e.g., < 45) Sustained and specialized officer trainingSustained and specialized officer training Active engagement in SA and MH treatmentActive engagement in SA and MH treatment Dual focus on treatment and surveillanceDual focus on treatment and surveillance Specialized caseloads more effective w CODsSpecialized caseloads more effective w CODs -Lower rates of revocation, arrest, incarceration -Better linkage with community treatment services

19. Community Supervision and CODs Problem-solving approachProblem-solving approach -Higher revocation threshold -Wide range of incentives and sanctions -Flexibly apply sanctions -Avoid sanctions that remove participants from treatment Relationship quality important (trust, caring-fairness, avoid punitive stance) – “firm but fair” Relationship quality important (trust, caring-fairness, avoid punitive stance) – “firm but fair” (See Skeem et al., 2006, 2009) 19

20. Court Based Interventions: Clinical Considerations Fred Osher, M.D.

21. Awareness: Consequences of Co-occurring Disorders Increased vulnerability to relapse and rehospitalization More psychotic symptoms Inability to manage finances Housing instability and homelessness Noncompliance with medications and treatment Increased vulnerability to HIV infection and hepatitis

22. Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C Persons with Substance Use Disorders had 2.95 (1.25-6.86) increased chance of having HIV 1.74 (1.20-2.51) increased chance of having HBV 2.42 (1.62-3.63) chance of having HCV Rosenberg et al., A J Public Health, 2001

23. Consequences of Co-occurring Disorders (cont.) Lower satisfaction with familial relationships Increased family burden Violence Return to Incarceration Increased depression and suicidality Higher service utilization and costs

24. Principles of care 1.Integrated treatment 2.Screening, Assessment, and Individualized Treatment Planning 3.Assertiveness 4.Close monitoring 5.Longitudinal perspective 6.Harm reduction 7.Stages of change 8.Stable living situation 9.Cultural competency and consumer centeredness 10.Optimism

25. 1.Integrated treatment Traditional models of treatment for dual disorders results in poor outcomes no treatment -- high utilization of E.R., jails, hospitals sequential treatment parallel treatment -- burden of integration on individual Fragmentation Integrated treatment associated with better outcomes in SMI and perhaps non-SMI

26. Past Year Mental Health Care and Treatment for Adults Aged 18 or Older with Both Serious Mental Illness and Substance Use Disorder 26 Source: NSDUH (2008)

27. FIDELITY TO DUAL DIAGNOSIS PRINCIPLES

28. 2. Screening, Assessment, and Individualized Treatment Planning Definition: Screening A formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a co-occurring substance or mental disorder. The screening process for co-occurring disorders (COD) seeks to answer a “yes” or “no” question: Does the substance abuse [or mental health] client being screened show signs of a possible mental health [or substance abuse] problem? Note that the screening process does not necessarily identify what kind of problem the person might have, or how serious it might be, but determines whether or not further assessment is warranted.

29. Council of State Governments Justice Center 29 A Framework for Prioritizing Target Population

30. 2. Screening, Assessment, and Individualized Treatment Planning Definition: Assessment A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor/therapist to understand the client’s readiness for change, problem areas, COD diagnosis, disabilities, and strengths. An assessment typically involves a clinical examination of the functioning and well-being of the client and includes a number of tests and written and oral exercises. The COD diagnosis is established by referral to a psychiatrist or clinical psychologist. Assessment of the COD client is an ongoing process that should be repeated over time to capture the changing nature of the client’s status.

31. 1. Evaluate pressing needs 2. Determine motivation to address substance use/mental health problems 3. Select target behaviors for change 4. Determine interventions/conditions to achieve desired goals 5. Choose measures to evaluate the intervention 6. Select follow-up times to review the plan. Individualized Treatment Planning - Steps

32. 3.Assertiveness Responsibility of systems to support outreach and engagement services Successful interventions: “go wherever the client is” In-reach to institutional settings work with family, landlords and employers Forensic Assertive Community Treatment (FACT)

33. 4.Close monitoring Intensive supervision needed until stable Sometimes coercive, always persuasive representative payeeship mandatory substance abuse treatment urine testing The essence of court-based interventions

34. 5.Longitudinal perspective Mental health, substance use disorders, and disease are chronic, relapsing conditions Treatment occurs continuously over years Progress measured over time What is the courts role in the recovery trajectory

35. 6.Harm reduction strategies Assume: continuum from abstinence  problematic use  abuse/dependence reducing quantity/frequency of use decreases likelihood of negative consequences Provide alternatives to traditional abstinence only philosophies More likely to engage those who don’t yet have abstinence as a goal Tough concept in drug court context

36. 7.Stages of change Engagement - connecting people to treatment Persuasion - convincing engaged clients to accept treatment Active treatment - range of behavioral, psychoeducational and medical interventions Relapse prevention - prevention and management of relapses

37. COURSE OF ATTAINING STABLE REMISSION (Drake et al, 1997)

38. 8.Stable living situation Not having a home makes assessment difficult and protracted Range of safe, affordable housing options are necessary safe havens or low demand residences for engagement and persuasion alcohol and drug free housing during active treatment and relapse prevention Separate conditions and treatment from housing Flexibility and tolerance required to retain people in housing

39. 9.Cultural competency and consumer centeredness Seek to understand - don’t assume a shared set of values or impose one’s own Respect cultural differences Value the consumer’s point of view

40. 10.Optimism Critical ingredient for recovery Hope as an antidote to despair Must have courage to connect with the reality of despair Share belief that because the problems are severe, the person deserves help Create a vision of what a hopeful outcome might be Peer supervision and training to bolster staff optimism

41. Integrating Treatment with Supervision

42. Transformation: Integrated Public Health- Public Safety Court Strategies (NIDA 2006) Blends functions of criminal justice and treatment systems to optimize outcomes Community- based treatment Opportunity to avoid incarceration or criminal record Close supervision Consequences for noncompliance are certain and immediate

43. What is the capacity of your community behavioral health providers to serve the target population and willingness to partner with the court diversion efforts? What is the quality of behavioral health services available to the target population? What is the priority given to criminal justice involved clients for community behavioral services? Questions for Discussion

44. Q&A 51