Co-Occurring Disorders 102

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 instruments • Conceptual model to drive COD services (Risk-Need-Responsivity) • Treatment modifications for CODs • Special populations and CODs

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

4. 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)

5. 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

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

7. Screening—Substance Abuse • Simple Screening Instrument • TCU Drug Screen–II • ASI–Alcohol and Drug Abuse sections • GAIN–SS

8. 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

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

10. Instruments for Adolescents • CAFAS • GAIN • MAYSI-2 • PESQ • POSIT

11. Other Screening Domains • Motivation • Offender Risk and Needs • Trauma and PTSD

12. Instruments—Motivation and Stages of Change • CMRS • RCQ • SOCRATES • TCU Treatment Motivation Scales • URICA

13. Instruments—Offender Risk and Needs • HCR-20 • LCSF • LSI-R • PCL-SV • RANT • START

14. 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

15. 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

16. 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

17. 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 (PCL-C) • Trauma Symptom Inventory (TSI)

18. 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

19. 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

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

21. 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

22. 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 • Motivationfor treatment • Family and social relationships • Physical health status and medical history

23. Conceptual Model of Services • Specialized Treatments • Illness Management & Recovery (IMR), Integrated Group Therapy (IGT) • Seeking Safety

24. 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

25. “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

26. “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

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” • Antisocial attitudes • Antisocial friends and peers • Antisocial personality pattern • Substance abuse • Family and/or marital factors • Lack of education • Poor employment history • 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-building • Allows offenders to respond effectively to interventions

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

32. 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

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

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

35. 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

36. CODProgram Phases • Orientation • Intensive treatment • Relapse prevention/transition

37. Orientation Phase • Comprehensive assessment • Persuasion and engagement groups • Treatment plan or contract • Introduction to recovery process

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

39. Relapse Prevention/Transition Phase • Education about the relapse process • Relapse prevention plan • Transition plan • Case managers or transition coordinators

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

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

42. 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)

43. 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

44. 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)

45. 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 • Casemanagement and community supervision

46. 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)

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

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

49. 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

50. 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