Co-occurring substance use and mental disorders in the criminal justice system: a new frontier of clinical practice and research.

This editorial introduces this special section of the Psychiatric Rehabilitation Journal, which focuses on justice-involved persons with co-occurring mental and substance use disorders (CODs). It contains seven original articles examining CODs among justice-involved populations that vary by gender, age, setting (e.g., community/ court, jail, prison), environment (urban, rural), geographic region, and nationality. (PsycINFO Database Record

Racial disparities in substance abuse treatment and the ecological fallacy.

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.

What does not work? Expert consensus on discredited treatments in the addictions.

Evidence-based practice promotes those research-supported treatments that have proven effective, but it rarely identifies discredited treatments that are to be avoided. We sought to establish a professional consensus on discredited addiction treatments using Delphi methodology. A panel of 75 experts participated in a 2-stage study, reporting familiarity with 65 treatments and rating these on a continuum from "not at all discredited" to "certainly discredited." We report their composite opinions and significant differences that occurred as a function of the panelists' theoretical orientation. The results require careful interpretation, but do offer a cogent first step in identifying a professional consensus of discredited treatments for addictions.

Organizational factors and collaboration and integration activities in criminal justice and drug abuse treatment agencies.

Despite strong interest in improving collaborations between correctional and substance abuse treatment organizations, there is a lack of empirical data describing the existing practices. The current study used a national survey of correctional administrators to examine organizational factors related to cross-agency collaboration and integration activities between corrections and substance abuse treatment organizations. Using a measure of collaboration that scaled cross-agency activities from less structured, informal networking and coordination to more structured and formalized levels of cooperation and collaboration, we found that different correctional settings (e.g., community corrections, jails, prisons) differed significantly in terms of their collaborative activities with substance abuse treatment agencies. We also found that the organizational characteristics that were associated with different levels of collaboration and integration differed across the correctional settings. Further research is needed to better understand how and why correctional agencies decide to formalize collaborative arrangements with treatment agencies and whether these efforts lead to more favorable outcomes.

When goals diverge: Staff consensus and the organizational climate.

A sample of correctional officers and prison substance abuse treatment staff collected by the National Criminal Justice Treatment Practices Survey is used to provide an exploratory study of an aspect of organizational culture consisting of consensus (agreement) among prison personnel regarding their beliefs about rehabilitation in the presence of conflicting organizational goals and aspects of the organizational climate important to change. Findings show that among those staff members responding to the survey, the belief in rehabilitation scale mean score was associated with higher levels of organizational commitment, and interdepartmental coordination. However, an hierarchical linear modeling (HLM) analysis that used an index score derived from the standard deviation for staff consensus regarding these same beliefs about rehabilitation produced a different pattern of results, showing that high levels of consensus were associated with job frustration, cynicism towards the ability of the institution to change, and lower levels of organizational commitment. The authors conclude that, although the sample may not express the beliefs of corrections officers or prison-based treatment staff at large, within the sample, consensus appeared to play a unique role in evaluating the effect of divergent goals on organizational climate as it relates to change, and warrants consideration when considering the effects of organizational climate.

Constructive conflict and staff consensus in substance abuse treatment.

Previous studies demonstrated the relationship between consensus among both staff and clients with client engagement in treatment and between client consensus and 1-year treatment outcomes. The present article explores the correlates of staff consensus, defined as the level of agreement among staff as to the importance of treatment activities in their program, using a national sample of 80 residential substance abuse treatment programs. Constructive conflict resolution had the largest effect on consensus. Low client-to-staff ratios, staff education, and staff experience in substance abuse treatment were also significantly related to consensus. Frequency of training, an expected correlate of consensus, was negatively associated with consensus, whereas frequency of supervision was not a significant correlate. The implications of the findings for future research and program improvement are discussed.

Client consensus on beliefs about abstinence: effects on substance abuse treatment outcomes.

Organizational culture, as evinced by consensus regarding staff and client beliefs and values, has been shown to affect client engagement in residential substance abuse treatment. The present paper extends this work to treatment outcomes. Secondary analysis of data from a "Beliefs About Abstinence Scale," used in the Drug Abuse Treatment Outcomes Study (DATOS), was conducted for 76 programs, including outpatient methadone treatment, outpatient drug-free, short-term inpatient, and long-term residential programs. Findings show that higher levels of client consensus after 1 month of treatment were associated with less use of drugs and alcohol at 1-year follow-up, after controlling for the mean of the scale score, gender, age, client substance use at baseline and treatment modality. The implications of the results for substance abuse treatment are discussed.

Specialized Prisons and Services: Results From a National Survey.

Findings from the National Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) National Criminal Justice Treatment Practices survey are examined to describe types of services provided by three types of prisons: those that serve a cross-section of offenders, those that specialize in serving offenders with special psychosocial and medical needs, and those that specialize in serving legal status or gender specific populations. Information is presented on the prevalence and type of specialized prisons and services provided to offenders as reported by wardens and other facility directors drawn from a nationally representative sample of prisons. Additional analyses explore organizational factors that differentiate prisons that serve specialized populations including staffing, training, other resources, leadership, and climate for change and innovation. Implications for expanding and improving services for special populations in correctional settings and the values of specialized prisons are discussed.

The contribution of consensus within staff and client groups as well as concordance between staff and clients to treatment engagement.

Two nonspecific organizational factors-consensus, defined as agreement within staff and client groups, and concordance, defined as agreement between staff and client groups-were shown to influence client engagement in treatment in a national sample of 80 residential substance abuse treatment programs including 595 staff and 3,732 clients. Agreement was tested using a combined therapeutic community, cognitive-behavioral therapy, and 12-step treatment scale completed by staff and clients. Treatment engagement was measured by the combined scores on the three scales completed by the clients, including engagement, rapport with the counseling process, and confidence in treatment. Within-group consensus was measured by the standard deviations of the mean scores, whereas between-groups concordance was measured by the standard error of the difference between staff and client mean scores. Regression analyses showed that staff consensus was a significant independent predictor of client treatment engagement (p < .05), whereas client consensus approached significance (p < .10). Concordance was also a significant predictor of client engagement (p < .002) after controlling for staff and client consensus. The potential contribution of the findings to a better understanding of program quality and effectiveness of programmatic interventions is discussed.

Recovery-oriented perceptions as predictors of reincarceration.

The present prospective study explored whether a specific class of client subjective assessments predicts later recovery. Measures of client perceptions of self-change in substance abusers were obtained a year after release from a prison-based therapeutic community. Analyses assessed the contribution of these perceptions-along with motivation, age, and risk index of social deviancy-in predicting reincarceration at 3-year follow-up. Results showed that two factors (Individual Growth and Socialization) significantly differentiated reincarceration and nonreincarceration at 1-year postrelease and significantly predicted reincarceration at 3-year follow-up. Findings underscore the relevance of perceptions of self-change early in recovery to later recovery behaviors. Research on recovery factors needs a uniform assessment protocol, which organizes client perceptions, beliefs, and attributions in accordance with a recovery stage framework.

The promise of prison-based treatment for dually diagnosed inmates.

The Stay'n Out therapeutic community was created 25 years ago, the first rigorously evaluated prison program that demonstrated recidivism reduction. Since then, there has been a growing appreciation for the recidivism-reducing benefit of substance abuse treatment and the general understanding has been reached that prison treatment for substance abuse is good for the public interest. A number of replicated outcome studies have led to increases in treatment capacity in most state correctional systems, primarily utilizing the therapeutic community model. In contrast, efforts to introduce treatment for offenders with co-occurring mental illness and substance abuse disorders (COD) are only beginning. This article describes developments in prison substance abuse treatment and reentry programs and offers some guiding observations from prison substance abuse treatment history that could facilitate the development of COD treatment. Lessons learned include that: public safety (i.e., recidivism reduction) is a primary goal; personal accountability as a basic treatment value facilitates cooperation between treatment and correctional staff; self-help approaches foster more ambitious treatment goals than just symptom reduction; and well-run treatment programs often ease the burden of correctional administration.