1 Court-Based Interventions and Co-Occurring Disorders Florida Partners in Crisis 2012 Annual Conference and Justice Institute Orlando, Florida, July 13,

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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

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Workshop Outline

I.I. Overview of workshopOverview of workshop

II.II. Integrated screening and assessmentIntegrated screening and assessment

III.III. Modifications to court program Modifications to court program structure and treatmentstructure and treatment

IV.IV. Clinical Considerations: Principles of Clinical Considerations: Principles of care for CODscare for CODs

V.V. Linking to EBP’s in the communityLinking to EBP’s in the community

VI.VI. Q & AQ & A

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

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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)

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Persons with CODs

Repeatedly cycle through the criminal justice Repeatedly cycle through the criminal justice and treatment systemsand treatment systems

Experience problems when not taking Experience problems when not taking medications, not in treatment, experiencing medications, not in treatment, experiencing mental health symptoms, using alcohol or drugsmental health symptoms, using alcohol or drugs

Small amounts of alcohol or drugs may trigger Small amounts of alcohol or drugs may trigger recurrence of mental health symptomsrecurrence of mental health symptoms

Antisocial beliefs similar to other offendersAntisocial beliefs similar to other offenders More criminal risk factors than other offendersMore criminal risk factors than other offenders

Conceptual Model of COD Treatment Services in Specialty Courts

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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 Focus on areas of functional impairment that

would prevent effective drug court participationwould prevent effective drug court participation• Examine longitudinal interaction of disordersExamine longitudinal interaction of disorders• Assess participant motivationAssess participant motivation

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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 Education regarding individual diagnoses

and interactive effects of CODsand interactive effects of CODs• ““Criminal thinking” groups Criminal thinking” groups • Basic life management and problem-solving Basic life management and problem-solving

skills skills

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COD Program Phases

• OrientationOrientation

• Relapse prevention/transitionRelapse prevention/transition

• Intensive treatment Intensive treatment

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 policies Extended exit and re-entry policies • Treatment may last for more than one yearTreatment may last for more than one year

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 More emphasis on education and support rather

than compliance and sanctionsthan compliance and sanctions• Motivational interventions in both group and Motivational interventions in both group and

individual settingsindividual 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

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Modifying Treatment for Cognitive Impairment

• Minimize need for abstraction (e.g., Minimize need for abstraction (e.g.,

use concrete, specific scenarios) 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 focusedKeep role plays short and focused

(Bellack, 2003)(Bellack, 2003)

Program Modifications for CODs

• Supplementary servicesSupplementary services (COD treatment (COD treatment groups, medication clinic, case groups, medication clinic, case management/crisis intervention)management/crisis intervention)

• TracksTracks within specialty court programs within specialty court programs

• COD docketsCOD dockets• TransferTransfer between drug courts, mental between drug courts, mental

health courts, COD dockets health courts, COD dockets

• Extended program Extended program durationduration (e.g., 18 mos.) (e.g., 18 mos.)

• Blended Blended screening and assessmentscreening and assessment

• Specialized supervision teamsSpecialized supervision teams15

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• Community partnerships for COD/MH servicesCommunity partnerships for COD/MH services• Recovery-oriented treatment planning and case Recovery-oriented treatment planning and case

managementmanagement• 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

Modifying Court Hearings

• More frequent court hearings may be neededMore frequent court hearings may be needed• Hearings provide a good opportunity to recognize Hearings provide a good opportunity to recognize

and reward positive behavioral changeand 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

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Community Supervision and CODs

• Specialized caseloadsSpecialized caseloads (MH/COD)

• Smaller caseloads (e.g., < 45)

• Sustained and specialized Sustained and specialized officer trainingofficer training

• Active engagement in Active engagement in SA and MH treatmentSA and MH treatment

• Dual focus Dual focus on treatment and surveillanceon treatment and surveillance

• Specialized caseloads more effective w CODsSpecialized caseloads more effective w CODs- Lower rates of revocation, arrest, incarcerationLower rates of revocation, arrest, incarceration- Better linkage with community treatment servicesBetter linkage with community treatment services

Community Supervision and CODs

• Problem-solvingProblem-solving approachapproach- Higher revocation thresholdHigher revocation threshold- Wide range of incentives and sanctionsWide range of incentives and sanctions- Flexibly apply sanctionsFlexibly apply sanctions- Avoid sanctions that remove participants Avoid sanctions that remove participants

from treatmentfrom treatment• Relationship quality important Relationship quality important (trust, (trust,

caring-fairness, avoid punitive stance) – caring-fairness, avoid punitive stance) – “firm but fair”“firm but fair”

(See Skeem et al., 2006, 2009)(See Skeem et al., 2006, 2009) 19

Court Based Interventions: Clinical Considerations

Fred Osher, M.D.

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

Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C

0%

5%

10%

15%

20%

25%

Seroprevalnce Rates in SMISample

HIV (N=931) HBV (N=751)

HCV(N=751)

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

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

Principles of care

1. Integrated treatment2. Screening, Assessment, and Individualized Treatment Planning3. Assertiveness4. Close monitoring5. Longitudinal perspective6. Harm reduction7. Stages of change8. Stable living situation9. Cultural competency and consumer

centeredness10. Optimism

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

Past Year Mental Health Care and Treatment for Adults Aged 18 or Older with Both Serious Mental Illness and Substance Use Disorder

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Source: NSDUH (2008)

FIDELITY TO DUAL DIAGNOSIS PRINCIPLES*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38

Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E ; n=61) vs. Low-Fidelity ACT Programs (G; n=26).

0

10

20

30

40

50

60

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.

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.

Council of State Governments Justice Center 29

A Framework for Prioritizing Target Population

Low Criminogenic Risk

(low)

Medium to High Criminogenic Risk

(med/high)

Low Severity of Substance Abuse

(low)

Substance Dependence

(med/high)

Low Severity of Substance Abuse

(low)

Substance Dependence

(med/high)

Low Severity of

Mental Illness(low)

Serious Mental Illness

(med/high)

Low Severity of

Mental Illness(low)

Serious Mental Illness

(med/high)

Low Severity of

Mental Illness(low)

Serious Mental Illness

(med/high)

Low Severity of

Mental Illness(low)

Serious Mental Illness

(med/high)

Group 1I – L CR: lowSA: lowMI: low

Group 2II – L CR: lowSA: lowMI: med/high

Group 3III – L CR: lowSA: med/highMI: low

Group 4IV – L CR: lowSA: med/highMI: med/high

Group 5I – H CR: med/highSA: lowMI: low

Group 6II – H CR: med/highSA: lowMI: med/high

Group 7III – H CR: med/highSA: med/highMI: low

Group 8IV – HCR: med/highSA: med/highMI: med/high

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.

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

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)

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

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

6. Harm reduction strategies

Assume: continuum from abstinenceproblematic 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

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

COURSE OF ATTAINING STABLE REMISSION (Drake et al, 1997)QuickTime™ and aGraphics decompressorare needed to see this picture.

0 mo. 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nt

Assessment Point

Pre-engagement

Engagement

Early Persuasion

Late Persuasion

Early Active Treatment

Late Active Treatment

Relapse Prevention

Recovered

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

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

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

Integrating Treatment with Supervision

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

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

Q&A

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