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Roger H. Peters, Ph.D., University of South Florida; [email protected] Co-Occurring Disorders 102 Goals of this Presentation Review: • Available screening instruments • Conceptual model to drive COD services (Risk-Need-Responsivity) • Treatment modifications for CODs • Special populations and CODs 2 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 Survey Results: Offender Screening Wide variation in types of SA screening instruments administered 32% of sites used no SA screening instruments 42% of sites did not use a standardized SA screening instrument (Taxman et al., 2007) 4 Screening for CODs • Routine screening for both sets of disorders • Criminal risk level • Acute MH and SA symptoms: • Suicidal thoughts and behavior • Depression, hallucinations, delusions • Potential for drug/alcohol withdrawal • History of MH treatment including use of meds • Determine need/urgency for referral Screening—Mental Health • • • • • Brief Jail Mental Health Screen Mental Health Screening Form–III MINI–M CODSI (Sacks et al, 2007) GAIN–SS 6 Screening—Substance Abuse • • • • Simple Screening Instrument TCU Drug Screen–II ASI–Alcohol and Drug Abuse sections GAIN–SS 7 Screening—Trauma and PTSD • Clinician-Administered PTSD Scale for DSM-IV • Impact of Events Scale • Primary Care PTSD Screen • PTSD Checklist–Civilian Version • Trauma Symptom Inventory 8 Specialized Screens • BASIS-24 • Centre for Addiction and Mental Health Concurrent Disorders Screener (CAMHCDS) • Psychiatric Diagnostic Screening Questionnaire (PDSQ) 9 Instruments for Adolescents • • • • • CAFAS GAIN MAYSI-2 PESQ POSIT 10 Other Screening Domains • Motivation • Offender Risk and Needs • Trauma and PTSD 11 Instruments—Motivation and Stages of Change • • • • • CMRS RCQ SOCRATES TCU Treatment Motivation Scales URICA 12 Instruments—Offender Risk and Needs • • • • • • HCR-20 LCSF LSI-R PCL-SV RANT START 13 Trauma and Victimization • Female offenders frequently have been victims of physical or sexual violence • Trauma history—should be expectation for women in CJ settings • Impact of violence is widespread, can impair recovery from MH and SA disorders Trauma and PTSD Screening Issues • PTSD and trauma are often overlooked in screening • Other diagnoses are used to explain symptoms • Result—lack of specialized treatment, symptoms masked, poor outcomes Screening for Trauma and PTSD • All 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 details • Many simple, non-proprietary screening instruments available • Positive screens should be referred for more comprehensive assessment 16 Screening Instruments for Trauma and PTSD • Clinician-Administered PTSD Scale for DSM-IV (CAPS) • Impact of Events Scale (IES) • Primary Care PTSD Screen (PC-PTSD) • PTSD Checklist—Civilian Version (PCLC) • Trauma Symptom Inventory (TSI) 17 Admission Criteria and CODs • Excluding persons with CODs is NOT a viable option • How to determine eligibility for services? • Triage to specialized COD services • Target moderate to high criminal risk levels Assessing Program Eligibility 1. Review existing program resources to work with co-occurring disorders Staff with MH and SA treatment experience Linkages with institutional and communitybased MH and SA services Specialized “tracks,” groups, or other services for co-occurring disorders Psychiatric/medication consultation 19 Assessing Program Eligibility 2. Determine functioning level required for program participation Treatment groups Therapeutic communities Community supervision Employment and peer support programs 20 Assessing Program Eligibility 3. Examine broad categories of functioning Cognitive functioning Major mental health symptoms Unusual behaviors Ability to interact with staff and participants (e.g., group settings) How responds to stress Reading, language abilities 21 Key Assessment Information • Scope and severity of MH and SA disorders • Pattern of interaction between the disorders • Conditions associated with occurrence and maintenance of the disorders • Criminal-antisocial beliefs • Motivation for treatment • Family and social relationships • Physical health status and medical history 22 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 Higher Risk Populations • • • • • Greater criminogenic needs • CODs Specialized Supervision Caseload 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 Treatments Illness Management & Recovery (IMR), Integrated Group Therapy (IGT) Seeking Safety Risk-Need-Responsivity (RNR) • The RISK principle tell us WHO to target • The NEED principle tells us WHAT to target • The RESPONSIVITY principle tells us HOW to target “Risk” Principle • Goal is to match the level of services to the offender’s likelihood to re-offend • Provides guidance re. WHO to target for program interventions • Adjust interventions, structure, and supervision by risk level “Need” Principle • Assess criminogenic needs and address these needs through focused interventions • Place higher-risk/higher-need offenders in treatment services • Prioritize a person’s “high” needs in coordinating services 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) Criminogenic Needs—“Big 8” 1. Antisocial attitudes 2. Antisocial friends and peers 3. Antisocial personality pattern 4. Substance abuse 5. 6. 7. 8. Family and/or marital factors Lack of education Poor employment history Lack of prosocial leisure activities Interventions Cognitive skills to address ‘criminal thinking’, positive peer supports, problemsolving skills Interventions Substance abuse treatment Co-occurring disorders treatment Job training/employment readiness “Responsivity” Principle • Optimizing offenders’ engagement, learning, and skill-building • Allows offenders to respond effectively to interventions Responsivity— general strategies • General approaches for providing interventions for offenders with CODs - Cognitive-behavioral - Social learning Responsivity— fine tuning • 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 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 problemsolving skills 33 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 Stage-Specific Treatment • People 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 planning • Allows development of stage-specific treatment for co-occurring disorders • Interventions are more likely to address goals that are valued by the individual 35 COD Program Phases Orientation Intensive treatment Relapse prevention/transition 36 Orientation Phase • • • • Comprehensive assessment Persuasion and engagement groups Treatment plan or contract Introduction to recovery process 37 Intensive Treatment Phase • • • Individual and group treatment Broad array of cognitive-behavioral interventions Specialized dual diagnosis interventions 38 Relapse Prevention/ Transition Phase • • • • Education about the relapse process Relapse prevention plan Transition plan Case managers or transition coordinators 39 Treatment Modifications Longer duration of treatment More extensive assessment Emphasis on psychoeducational and supportive approaches Higher staff ratio, more MH staff 40 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 Modifying Treatment for Cognitive Impairment • • • • • Minimize need for abstraction (e.g., use concrete, specific scenarios) Have demonstrate skills Keep instructions brief Use audiovisual aids Keep role plays short and focused (Bellack, 2003) 42 Treating Female Offenders with CODs • • • • • Focus on trauma and spousal abuse Emphasis on education and job training Parenting skills Female role models and peer support Assertive outreach and crisis intervention 43 Treatments for Trauma and Substance Abuse • Seeking Safety (Najavits, 2002) • Trauma Recovery and Empowerment (TREM) (Harris, 1998) • Treating concurrent PTSD and cocaine dependence (Brady et al., 2001) • Substance Dependence Posttraumatic Stress Disorder Therapy (Triffleman, et al., 1999) 44 Key Transition Services • Development of re-entry or transition plan • Assistance to engage in community-based SA and MH treatment • Engagement in peer support and self-help networks to assist in recovery • Stable housing • Vocational training and employment support • Case management and community supervision 45 The APIC Model • Assess clinical and social needs and risk level • Plan for treatment and services • Identify required community programs • Coordinate the transition plan services (Osher, Steadman, & Barr, 2002) 46 APIC Reentry Checklist: Primary Domains ♦ Mental health services ♦ Psychotropic medications ♦ Housing ♦ Substance abuse services ♦ Health care/benefits ♦ Income/benefits ♦ Food/clothing ♦ Transportation ♦ Other 47 Effectiveness of Prison COD Treatment and Reentry—1 Year Reincarceration 50 40 30 33% 20 MH TC + aftercare 5% 16% 10 TC only 0 Total n=139 n=64 Sacks et al. 2004 n=32 n=43 48 Court Hearings and Judicial Monitoring • More frequent court hearings may be needed • Hearings provide a good opportunity to recognize and reward positive behavioral change • Specialized dockets - Less formal, smaller, more private - More frequent - Greater interaction between judge and participants - Include mental health professionals Community Supervision • Active involvement in court and community treatment teams, in-reach to jail and prison • Rapid crisis response capability • Monitor medication compliance (MH agencies) • Home visits useful • “Fugitive” warrants receive priority • Taper supervision over time Specialized Caseloads • Specialized MH/COD caseloads • Smaller caseloads with more intensive services (e.g., < 45) • Sustained and specialized officer training • Dual focus on treatment and surveillance • Active engagement in SA and MH services Specialized Caseloads • Relationship quality important (trust, caringfairness, avoid punitive stance)—“firm but fair” • Problem-solving approach vs. reliance on sanctions • Wide range of incentives and sanctions • Flexibly apply sanctions • Avoid sanctions that remove participants from treatment • Higher revocation threshold • Improved outcomes—lower rates of revocation, arrest, and incarceration (Skeem et al., 2009)