Co‐Occurring Disorders in Treatment‐Based Courts: Results of a National Survey

Drug courts and mental health courts have expanded rapidly in the past several decades to provide more efficient coordination of treatment and supervision of offenders with behavioral health problems. A significant number of offenders in these court‐based programs have co‐occurring mental and substance use disorders, which predict early termination, relapse, rearrest, and other negative outcomes. A web‐based national survey examined programmatic adaptations for co‐occurring disorders (CODs) among 54 drug courts, mental health courts, and freestanding COD dockets. COD dockets were smaller and of longer duration, and provided more intensive services than programs situated in drug courts or in mental health courts. However, more similarities than differences were noted across the different types of court‐based program. Key adaptations for CODs included extended program duration, highly intensive and integrated treatment, smaller, less formal, and more frequent hearings, and use of specialized supervision teams and dually credentialed staff. Copyright © 2012 John Wiley & Sons, Ltd.     

Effects of diversion on adults with co-occurring mental illness and substance use: outcomes from a national multi-site study

This quasi-experimental non-equivalent comparison group study examines outcomes for participants in eight programs conducting criminal justice diversion for people with co-occurring serious mental illness and substance use disorders compared with jail detainees eligible for diversion, but who were processed through standard criminal justice methods without diversion. Nearly 2000 participants were interviewed at baseline, and 1500 at 3 month and 1300 at 12 month follow-up to baseline. In these interviews, outcome measures of re-arrest, mental health functioning, substance abuse, quality of life, and service utilization were obtained. Those diverted were more likely to have received mental health counseling, mental health medication, and mental health hospitalization than those not enrolled in a diversion program, but were equally likely to have received substance abuse counseling. Overall, the differences in proportions receiving services between the two groups were small, even when these differences were statistically significant. The effect associated with diversion differed somewhat across the individual sites. However, overall cross-site pooled analyses revealed no outcome differences between groups on measures of mental health symptoms, substance use, criminal justice recidivism, or quality of life. Although the immediate benefit of diversion as an access mechanism to community treatment is indicated in pooled cross-site results, such access was driven by more coercive (pre-booking and court) models and results suggest that effecting substantially greater access to services or services use did not occur. The findings also suggest that mental health, substance abuse, and criminal justice outcomes remain dependent on the treatment intervention received, perhaps moderated by type of diversion intervention, rather than on a generic and initial diversion event.     

School-Based Mental Health Services: A Research Review

This paper provides a synthetic review of research on school-based mental health services. Schools play an increasingly important role in providing mental health services to children, yet most school-based programs being provided have no evidence to support their impact. A computerized search of references published between 1985 and 1999 was used to identify studies of school-based mental health services for children. Study inclusion was determined by (i) use of randomized, quasi-experimental, or multiple baseline research design; (ii) inclusion of a control group; (iii) use of standardized outcome measures; and (iv) baseline and postintervention outcome assessment. The application of these criteria yielded a final sample of 47 studies on which this review is based. Results suggest that there are a strong group of school-based mental health programs that have evidence of impact across a range of emotional and behavioral problems. However, there were no programs that specifically targeted particular clinical syndromes. Important features of the implementation process that increase the probability of service sustainability and maintenance were identified. These include (i) consistent program implementation; (ii) inclusion of parents, teachers, or peers; (iii) use of multiple modalities; (iv) integration of program content into general classroom curriculum; and (v) developmentally appropriate program components. Implications of these findings and directions for future research are discussed.     

Predictive validity of the MMPI-2 Restructured Clinical (RC) Scales in a batterers' intervention program

We examined the convergent and discriminant validity of the MMPI-2 Restructured Clinical (RC) scales in predicting relevant historical variables, treatment success, and recidivism in offenders enrolled in a batterers' intervention program. We used a sample studied previously by Petroskey, Ben-Porath, and Erez (2002), which included an ethnically diverse group of 483 men enrolled in a psychoeducational batterer's intervention program. We coded various historical variables (e.g., criminal history, substance abuse problems, mental health treatment, anger problems, and amount of partner violence), treatment dismissal, and recidivism up to 1 year posttreatment. Correlational analyses with the historical variables provided evidence of convergent and discriminant validity of the RC scales in this forensic sample. Regression analyses showed that these scales added to the historical variables in predicting treatment failure and recidivism. Relative risk analyses indicated the extent to which individuals entering treatment with elevated scores on RC4 and RC9 were at increased risk for these negative outcomes.     

Treatment outcomes for female offenders: relationship to number of Axis I diagnoses

This article describes a study that examined the relationship between multiple Axis I mental health diagnoses and treatment outcomes for female offenders in prison substance abuse treatment programs. Preliminary findings of the effectiveness of therapeutic community (TC) treatment, modified for female offenders, relative to a control cognitive behavioral treatment condition, are presented. The hypothesis--that participants who fit into multiple diagnostic categories have more dysfunctional symptoms and behaviors at baseline--was confirmed; however, a hypothesized relationship between the number of Axis I diagnoses and 6 month treatment outcomes across five domains (mental health, trauma exposure, substance use, HIV needle risk behaviors, and HIV sexual risk) was not supported. Across all Axis I mental health groups, TC treatment was significantly more effective than the control condition overall, as well as on measures of mental health symptoms and HIV sexual risk. These findings suggest that this TC treatment program, as modified, is an effective model for women with varied diagnoses and diagnostic complexities.     

Diverting multi-problem youth from juvenile justice: investigating the importance of community influence on placement and recidivism

In the U.S., diversion has increasingly become one of the most utilized alternatives to detention of delinquent youth. Programs providing diversion can vary greatly. Variations in program design make it difficult to evaluate the effectiveness of program outcomes. Utilizing hierarchical linear modeling, this study examines variations in outcome for ten program sites of the New York State MH/JJ Diversion Project. Program and youth predictors were evaluated on two outcomes: out-of- community placement and recidivism. At the individual level, significant mental health and substance abuse problems, age, prior placements, and use of wraparound funds were predictive of youth placements, while significant substance abuse problems were predictive of recidivism. Program variations were found to have a significant impact on youth outcomes. Specifically, sites providing direct (or "in house") care had significantly reduced rates of placement. Study results and implications for future research are discussed.     

Pre-arrest diversion of people with mental illness: Literature review and international survey

Mental health diversion is a process where alternatives to criminal sanctions are made available to persons with mental illness (PMI) who have come into contact with the law. One form of mental health diversion is pre-arrest, in which the police use their discretion in laying charges. Concomitant with the growth of pre-arrest diversion programs is a growing body of research devoted to the phenomenon. The purpose of this paper is to review the existing literature of pre-arrest diversion, and to report the results of an international survey of pre-arrest diversion programs we conducted to identify evidence-based practices. On the basis of our review and survey, we note that successful pre-trial programs appear to integrate relevant mental health, substance abuse and criminal justice agencies by having regular meetings between key personnel from the various agencies. Often, a liaison person with a mandate to effect strong leadership plays a key role in the coordination of various agencies. Streamlining services through the creation of an emergency drop-off center with a no-refusal policy for police cases is seen as crucial. While there is some indication that mentally ill offenders benefit from their participation in this form of diversion, the evaluative literature has not yet achieved the "critical mass" necessary to create generalizable, evidence-based knowledge. The absence of generally agreed-upon outcomes could lead to the inequitable application of basic principles of diversion. We suggest that indicators, benchmarks, and outcomes must be agreed upon if a comprehensive understanding of pre-arrest programs is to emerge.     

The multifactor offender readiness model

There has been a resurgence of interest in the rehabilitation of offenders. Research has consistently shown that rehabilitation programs for offenders, when they adhere to general principles of program design and delivery, will achieve significant reductions in recidivism. In this paper, we suggest that even greater reductions in recidivism can be achieved when readiness is addressed at the level of the individual offender, the program, and the context. A comprehensive understanding of readiness allows for fuller engagement in treatment, thus increasing probability of good treatment outcomes. We describe person, program, and context factors in a model of offender treatment readiness and discuss implications of the model for both assessment of offenders and for modification of low readiness.     

Characteristics of START Assessments Completed in Mental Health Jail Diversion Programs

Many different instruments have been developed to assist in the assessment of risk for violence and other criminal behavior. However, there is limited evidence regarding how these instruments work in the 'real world'. Even less is known about how these instruments might work for assessing risk in jail diversion populations, whether in research or practice. To address these knowledge gaps, the present study examined the characteristics of risk assessments completed by program staff (n?=?10) on 96 mental health jail diversion clients (72 men and 24 women) using the Short-Term Assessment of Risk and Treatability (START). The findings provide preliminary support for the reliability and validity of START assessments completed in jail diversion programs, the first evidence of the transportability of START outside psychiatric settings, and further evidence regarding the reliability and validity of START assessments completed in the field. They additionally support the consideration of an eighth, general offending risk domain in START assessments. Copyright ? 2012 John Wiley & Sons, Ltd.     

The Impact of Community Mental Health Programs for Australian Youth: A Systematic Review

Australia has undergone significant youth mental health reform over the past 10 years, leading to numerous studies examining the effects of community-based mental health care programs for Australian youth. However, no synthesis of this literature currently exists. Therefore, this systematic review aimed to: (1) describe the types of community-based mental health programs that have been delivered to Australian youth in the past 10 years; and (2) examine their impact in improving young people’s mental health symptomology and psychosocial functioning. A systematic search of the peer-reviewed literature was conducted. Studies were included if they evaluated the extent to which such programs improved mental health symptomology (e.g., depression, anxiety, substance use) and/or psychosocial outcomes (e.g., social functioning, school engagement, employment) for Australian youth aged 10–25 years. Thirty-seven studies were included. Four types of community-based youth mental health care programs were identified: therapy (n?=?16), case management (n?=?9), integrated ‘one-stop-shop’ (n?=?6) and lifestyle (n?=?6) programs. The majority of therapeutic programs were effective in reducing mental health symptomology. Case management and integrated approaches consistently yielded significant improvements in both symptomology and psychosocial outcomes. Lifestyle programs were effective in alleviating depressive symptoms, but inconclusive for other outcomes. This review provides support for youth-friendly, systemic, multidisciplinary and integrated assertive outreach models of community mental health care to improve outcomes for young Australians experiencing mental health concerns. Several recommendations for future research are provided to strengthen the local evidence-base supporting community mental health programs to ultimately enhance young people’s life trajectory.

     

Examining changes in procedural justice and their influence on problem‐solving court outcomes

The number of problem‐solving courts has grown substantially since the mid‐1990s. Research consistently indicates that participation in these courts lowers recidivism, which is often attributed to defendants’ increased perceptions of procedural justice in these programs. Yet, prior studies are limited in their focus, often examining interactions with the judge in a single court or examining defendant perceptions and outcomes at a single time point. In the present study, we investigate defendant perceptions of procedural justice with judges and case managers across multiple problem‐solving courts over time. Findings indicate that procedural justice varies across court actors and over time. Procedural justice is lower among judges than among case managers; however, changes in perceptions of procedural justice with the judge are associated with improved court outcomes. We suggest that defendant perceptions are variable and complex but important in explaining variations in outcomes.     

An analysis of post-booking jail diversion programming for persons with co-occurring disorders

For persons with co-occurring disorders, interaction with criminal justice systems is a frequent occurrence. As a result, a variety of diversionary programs have been developed nationwide. In this study, a total of 248 individuals with co-occurring disorders of serious mental illness and substance use disorders who had been arrested and booked on misdemeanor charges participated in a post-booking jail diversion program in two urban communities. A quasi-experimental design was used with individuals assigned to diversion or non-diversion status based upon the decision processes of the mental health-criminal justice systems. The effectiveness of the jail diversion program was evaluated from a variety of sources, including structured interviews, behavioral health service utilization patterns, and criminal justice recidivism patterns. Analyses revealed general main effects for time on many of the outcome variables, with few main effects or interaction effects detected on the basis of diversion status (diverted versus non-diverted). Across all measures assessing mental health and substance abuse, study participants displayed improvements over time, irrespective of their diversion status or program location. Participants generally displayed no significant changes in their rates of accessibility to, or frequency of use of, the various mental health, substance abuse, and other services, and few changes for diversion status were detected with regard to service utilization. Although a number of indicators of criminality and violence were reduced over time, these reductions were statistically insignificant, with changes for diversionary status or time identified at follow-up. These results are discussed in light of their implications for jail diversion programming and future research in this area.     

Mental Health Identification Practices of Jails: The Unmet Needs of the “Silent” Population

The overrepresentation of individuals with mental illness in the criminal/legal system is well documented. While professional associations urge diversion towards treatment, little is known about the practices these institutions use to identify this population. One understudied space in the criminal/legal continuum is jails. This exploratory study compares two types of mental health identification at jail booking to assess jail‐ and community‐based service outcomes by identification type (N = 2956): (a) staff observation and (b) a standardized screening instrument. Individuals identified through staff observation were significantly more likely to receive jail‐ and community‐based services, even though current symptomology and substance misuse were both significantly higher for individuals identified only by the screening instrument. These findings point to the importance of jails in providing stabilizing services during incarceration, but further, show the impact that identification practices have on individuals as they transition to the community. Community context showed varied rates of jail staff observations of mental illness, showing greater risks for individuals in rural communities. Implications include a need for system‐level changes by instituting evidence‐based identification practices in jails, and improving professional collaboration practices between mental health and criminal/legal practitioners as individuals enter and exit jails.     

Development of the Multicultural Mental Health Awareness Scale

The present study describes the development of an instrument to assess the multicultural competencies of mental health professionals in Australia. The scale was developed to assess the effectiveness of a multicultural mental health training program. Mental health professionals from Queensland, Australia (N = 268) participated in the study by completing a questionnaire battery. Items on the new scale were generated to parallel the Queensland Transcultural Mental Health Centre (QTMHC) training program's objectives. The results describe a 35‐item Multicultural Mental Health Awareness Scale. Factor analysis of the scale indicated three factors of multicultural counselling competencies: Awareness, Knowledge, and Skills. These factors were in line with the Sue et al. (1982) multicultural counselling competencies. The scale has satisfactory internal consistency, test–retest reliability, concurrent validity, and discriminant validity and can be used to evaluate the effectiveness of the multicultural competency training programs in mental health.     

Self‐Stigma,Mental Health Literacy,and Health Outcomes in Integrated Care

The authors describe research on the self‐stigma of mental illness and help seeking, mental health literacy, and health outcomes in an integrated care medical center. Results revealed that self‐stigma of mental illness and self‐stigma of seeking help had an inverse relationship with mental health literacy. No statistically significant relationships were found between health outcomes, either type of self‐stigma, and mental health literacy. The authors discuss these and other findings and offer research and counseling implications.     

Stigma and Client Satisfaction in Mental Health Services

Numerous studies have revealed that stigmatization of persons with mental health problems has a large array of negative consequences. One outcome that has been largely neglected is client satisfaction. In this empirical study, the link between 3 types of stigma experiences and client satisfaction is explored in a sample of clients (N = 741) of professional mental health services in Belgium. This relationship is compared with the link between stigma and general life satisfaction; and the role of the self‐concept in these relationships is explored. The results reveal that the association depends on the dimension of stigma under study. The findings stress the importance of studying multiple dimensions of stigma experiences, in addition to multiple outcomes.     

Evaluation of a cognitive‐behavioral intervention for high‐ and medium‐risk probationers

Reducing recidivism is a central goal of treatment programs for offenders. Preliminary evidence suggests that cognitive‐behavioral group interventions based on the National Institute of Corrections curriculum (Bush, Glick, & Taymans, 1997) may be effective in reducing recidivism rates among adult probationers. We evaluated the effectiveness of a program based on this curriculum among 167 high‐ and medium‐risk probationers assigned to this program and a comparison group of 120 high‐ and medium‐risk probationers matched on age and number of prior criminal charges. Improvements over prior studies included use of survival analytic methods and propensity score matching, a longer follow‐up interval, and examination of treatment effectiveness within ethnic groups. Relative to the comparison group, treatment group probationers were more likely to complete probation satisfactorily and survive longer before rearrest. Moreover, supplementary analyses suggested that ethnicity was associated with differences in intervention effectiveness. Treatment was predictive of lower recidivism rates among European Americans and African Americans but was less effective among Latino American probationers.     

Efficacy of a Mental Health Treatment Court with assertive community treatment

This study examined the efficacy of a Mental Health Treatment Court (MHTC) with diversion to treatment supported by an assertive community treatment (ACT) model of case management. A total of 235 participants were randomly assigned to either MHTC or treatment as usual (TAU) and assessed over a 2 year period. It was hypothesized that participants in the MHTC would decrease their criminal activity and improve their psychosocial functioning relative to participants receiving TAU. While there were offenders for whom neither treatment was effective, a majority in both groups decreased jail days and improved psychosocial functioning, with MHTC participants demonstrating greater gains in most areas. The impact of implementing the MHTC on community practices, and the value of integrating criminal justice and mental health systems, is discussed.     

Holistic representation in juvenile defense: An evaluation of a multidisciplinary children's defense team

This study describes the results of an evaluation of a holistic defense model for juvenile clients. Longitudinal, retrospective analysis of de‐identified data from clients (N = 308) measured individual variable outcomes, relationships, and project performance. Bivariate and multivariate analyses examined the strength of association and interrelationships among client and defense team variables. Findings indicate that holistic defense was significantly associated with improved outcomes among juvenile clients, including increased mental health assessment resulting in treatment, increased employment and educational attainment, and decreased odds of recidivism. Favorable court or dispositional outcomes, including lower adjudication or early termination from custody, were also reported. Further practice‐level, controlled research is necessary to evaluate these models and offer comparison to other models for holistic defense.