Roger H. Peters, Ph.D., University of South Florida; [e-mail]

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Co-Occurring Disorders 102

• Roger H. Peters, Ph.D., University of South
  Florida rhp_at_usf.edu

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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

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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

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Survey ResultsOffender 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)

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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

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ScreeningMental Health

• Brief Jail Mental Health Screen
• Mental Health Screening FormIII
• MINIM
• CODSI (Sacks et al, 2007)
• GAINSS

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ScreeningSubstance Abuse

• Simple Screening Instrument
• TCU Drug ScreenII
• ASIAlcohol and Drug Abuse sections
• GAINSS

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ScreeningTrauma and PTSD

• Clinician-Administered PTSD Scale for DSM-IV
• Impact of Events Scale
• Primary Care PTSD Screen
• PTSD ChecklistCivilian Version
• Trauma Symptom Inventory

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Specialized Screens

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

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Instruments for Adolescents

• CAFAS
• GAIN
• MAYSI-2
• PESQ
• POSIT

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Other Screening Domains

• Motivation
• Offender Risk and Needs
• Trauma and PTSD

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InstrumentsMotivation and Stages of Change

• CMRS
• RCQ
• SOCRATES
• TCU Treatment Motivation Scales
• URICA

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InstrumentsOffender Risk and Needs

• HCR-20
• LCSF
• LSI-R
• PCL-SV
• RANT
• START

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Trauma and Victimization

• Female offenders frequently have been victims of
  physical or sexual violence
• Trauma historyshould be expectation for women in
  CJ settings
• Impact of violence is widespread, can impair
  recovery from MH and SA disorders

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Trauma and PTSD Screening Issues

• PTSD and trauma are often overlooked in screening
• Other diagnoses are used to explain symptoms
• Resultlack of specialized treatment, symptoms
  masked, poor outcomes

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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 doesnt require
  discussion of specific details
• Many simple, non-proprietary screening
  instruments available
• Positive screens should be referred for more
  comprehensive assessment

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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 ChecklistCivilian Version (PCL-C)
• Trauma Symptom Inventory (TSI)

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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

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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 community-based
  MH and SA services
• Specialized tracks, groups, or other services
  for co-occurring disorders
• Psychiatric/medication consultation

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Assessing Program Eligibility

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

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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

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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

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Conceptual Model of Services
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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

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Risk Principle

• Goal is to match the level of services to the
  offenders likelihood to re-offend
• Provides guidance re. WHO to target for program
  interventions
• Adjust interventions, structure, and supervision
  by risk level

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Need Principle

• Assess criminogenic needs and address these needs
  through focused interventions
• Place higher-risk/higher-need offenders in
  treatment services
• Prioritize a persons high needs in
  coordinating services

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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)

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Criminogenic NeedsBig 8

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

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Interventions Cognitive skills to address
criminal thinking, positive peer supports,
problem-solving skills
Interventions Substance abuse treatment Co-occurri
ng disorders treatment Job training/employment
readiness
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Responsivity Principle

• Optimizing offenders engagement, learning, and
  skill-building
• Allows offenders to respond effectively to
  interventions

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Responsivitygeneral strategies

• General approaches for providing interventions
  for offenders with CODs
• Cognitive-behavioral
• Social learning

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Responsivityfine 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

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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

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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

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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

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COD Program Phases

• Orientation
• Intensive treatment
• Relapse prevention/transition

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Orientation Phase

• Comprehensive assessment
• Persuasion and engagement groups
• Treatment plan or contract
• Introduction to recovery process

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Intensive Treatment Phase

• Individual and group treatment
• Broad array of cognitive-behavioral interventions
  
• Specialized dual diagnosis interventions

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Relapse Prevention/Transition Phase

• Education about the relapse process
• Relapse prevention plan
• Transition plan
• Case managers or transition coordinators

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Treatment Modifications

• Longer duration of treatment
• More extensive assessment
• Emphasis on psychoeducational and supportive
  approaches
• Higher staff ratio, more MH staff

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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

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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)

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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

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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)

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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

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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)

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APIC Reentry Checklist Primary Domains

• ? Mental health services
• ? Psychotropic medications
• ? Housing
• ? Substance abuse services
• ? Health care/benefits
• ? Income/benefits
• ? Food/clothing
• ? Transportation
• ? Other

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Effectiveness of Prison COD Treatment and
Reentry1 Year Reincarceration
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MH
TC after-care
16
5
TC only
Total n139 n64 n32 n43
Sacks et al. 2004
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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

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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

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Specialized Caseloads

• Specialized MH/COD caseloads
• Smaller caseloads with more intensive services
  (e.g., lt 45)
• Sustained and specialized officer training
• Dual focus on treatment and surveillance
• Active engagement in SA and MH services

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Specialized Caseloads

• Relationship quality important (trust,
  caring-fairness, 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 outcomeslower rates of revocation,
  arrest, and incarceration (Skeem et al., 2009)