Community-based co-occurring disorder (COD) intermediate and advanced treatment for offenders

Against a backdrop of increasing concern about the adequacy of treatment for co-occurring substance use and mental disorders (typically known as "co-occurring disorders," or COD) in the criminal justice system, this article attempts to provide empirical evidence for a typology of levels of COD treatment for offenders in both prison and community settings. The paper investigates two levels of treatment programs for COD; "intermediate" programs, in which treatment programming has been designed primarily for offenders with a single disorder, and "advanced" programs, in which programming has been designed to provide integrated substance abuse treatment and mental health services. Findings from a national survey of program directors indicated that both intermediate and advanced COD treatment programs were similar in their general approach to substance abuse treatment, but differed considerably in their treatment of mental disorders, where the advanced programs employed significantly more evidence- and consensus-based practices. Results provide support for the distinction between intermediate- and advanced-level services for offenders with COD and support a typology that defines advanced programs as integrating a range of evidence- and consensus-based practices so as to modify treatment sufficiently to address both diseases.     

Challenges in implementing evidence-based treatment practices for co-occurring disorders in the criminal justice system

The presence of adults with mental health and substance abuse disorders within the criminal justice system has become increasingly evident over the past decade. Interventions and treatment services have been designed and research conducted in an effort to establish evidence-based practices that effectively address the complex needs of this population. However, adopting and implementing these evidence-based interventions and practices within the real-world setting of criminal justice environments is challenging. This article reviews the research literature related to evidence-based treatment practices for offenders with co-occurring mental health and substance abuse disorders and explores the inherent challenges of fitting these interventions and services within criminal justice settings.     

One year return to custody rates among co-disordered offenders

The extent to which therapeutic community (TC) methods meet the treatment needs of offenders with substance abuse disorders and co-occurring psychiatric disorders in prison is largely unknown. Very little research has been conducted with this population. The purposes of this study were to generate profiles of co-disordered drug offenders entering TC treatment in prison and to assess their post-release reincarceration rates, compared with drug offenders without psychiatric disorders. Extensive intake interview data for over 8,500 men and women who received treatment in one of 16 prison-based TCs in California were analyzed to produce profiles of co-disordered participants. Intake data come from a 5 year process and outcome evaluation of the California Department of Corrections' (CDC's) treatment initiative. Post-release reincarceration rates come from the CDC's Offender Based Information System. Compared with non-psychiatric disordered drug offenders, co-disordered offenders had substantially more severe substance abuse and criminal histories, in addition to their psychiatric impairment, at treatment entry. Logistic regression results indicated that, compared with drug offenders without psychiatric illness, co-disordered offenders were significantly more likely to be reincarcerated during the first year of their parole. These results suggest that prison treatment programs may need to use more comprehensive diagnostic assessments at intake to assess the diverse mental health needs of drug offenders with co-occurring psychiatric disorders and to develop treatment approaches suitable for this population.     

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.     

An examination of the assumptions of specialization, mental disorder, and dangerousness in sex offenders

Sex offenders have been singled out for differential treatment by the legal and mental health systems. This article attempts to inform law reform efforts and criminal justice mental health policy by examining the assumptions underlying differential legal and mental health treatment of sex offenders. These assumptions include the theories that sex offenders are mentally disordered and in need of treatment, specialists in sex crimes, and more dangerous than other criminal offenders. Empirical findings demonstrate that sex offenders are not specialists in sex crimes and are not mentally disordered. Examination of past research suggests that sex offenders are not at more risk than other criminal offenders to commit future sex crimes. Implications of research findings for selective prosecution of sex crime cases, mental health policy, sex offender legislation, and predictions of future dangerousness are discussed. Proposals for future research needs and law reform are presented.     

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.     

Umgang mit gefährlichen Straftätern in England und Wales

Forensic psychiatric institutions exist in all western European countries. Their organisation depends on a number of factors including the legal framework and societal attitudes towards mentally disordered offenders. This article describes and critically comments on the forensic psychiatric system in England and Wales, its legal framework and approaches to dealing with dangerous offenders. England and Wales have a long forensic psychiatric tradition with the first high security hospital, Broadmoor hospital, having been established in 1863. Evidence-based treatment approaches in forensic hospitals as well as in prisons, training of forensic psychiatrists and research in the field of forensic psychiatry have gained international recognition. However, there are some worrying aspects in the system of forensic psychiatric care and the criminal justice system more generally, in particular the high and still increasing number of prisoners in comparison with other European countries, the low age of criminal responsibility, long sentences, increasing length of stay in forensic care and the increasingly risk averse culture. A number of differences to the German system can be found; one such difference relates to the role of criminal responsibility which is irrelevant for decisions regarding commitment in England and Wales. Only the mental state and need for treatment at the time of trial (or later assessment in prison) determine whether an offender is admitted to psychiatric care or receives a prison sentence. A number of new initiatives have been launched in recent years resulting in an increasing number of individuals being detained in forensic psychiatric and criminal justice institutions, in particular the initiative for the detention and treatment of individuals with so-called dangerous and severe personality disorders, the sexual offenders register and the new sentence of indeterminate imprisonment for public protection. These initiatives have been the subject of a number of complaints to the European Court of Human Rights. Nevertheless, the trend towards a more and more risk averse culture continues.     

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.     

COD services in community correctional settings: an examination of organizational factors that affect service delivery

Little is known about service delivery for those in the correctional system with co-occurring mental health and substance abuse disorders (COD). Using data from the National Criminal Justice Treatment Practices survey (NCJTP) on community corrections and jail agencies, this study found that correctional organizations that offer COD services differ from agencies that do not. Organizations that respond to the needs of COD offenders tend to be more "service friendly," rank higher on measures of various dimensions of organizational climate that embrace learning and goal achievement, and tend to adopt more innovations, particularly those classified as evidence-based practices. These survey findings indicate that correctional agencies who serve COD offenders are in a better position to be responsive to the changing service needs of the populations, and are more likely to be able to balance public safety and treatment goals. Future steps to develop support environments for COD assessment and treatment services are discussed in light of these findings.     

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.     

Predictors of Criminal Charges for Youth in Public Mental Health During the Transition to Adulthood

Dual involvement with the mental health system and justice system is relatively frequent for young adults with mental health problems, yet the research on factors predictive of dual involvement is incomplete. This study extends past research on predictors of criminal charges for people in the public mental health system in four ways. First, this study expands the longitudinal study period to include the time of transition to adulthood, from 16 to 25 years of age. Second, this study separately predicts specific types of criminal charges, including violent, property, drug, and nuisance charges. Third, this study examines whether residential treatment or inpatient hospitalization are predictive of criminal charges. Fourth, this study stratifies prediction by gender. Findings indicated high levels of dual involvement during this time period. In general, males and people diagnosed with substance use disorder or conduct disorder were more likely to have a criminal charge. Other predictors of specific criminal charges varied by gender. Residential treatment, inpatient hospitalization, and anxiety disorder were generally not related to criminal charges. Implications for cross-system collaboration and early intervention are discussed.     

Denial and minimization among sex offenders

A review of empirical studies of offenders—particularly sex offenders, and more particularly those who offend against children—demonstrates that denial of offenses and minimization of offending behavior are quite common at every stage of the criminal justice process. This is true during police interviews, during pretrial and presentencing mental health evaluations, among incarcerated offenders, among offenders seeking treatment, among offenders facing parole review, and among offenders already released into the community. This review highlights gaps in the research literature arising from inconsistencies in the definitions and measurement of denial and minimization, from the stage of adjudication or treatment at which measurements are made, and from the use of polygraphy to increase disclosures. Despite these limitations on the generalizability of empirical findings, it appears beyond dispute that many sex offenders maintain their innocence in the face of evidence to the contrary or even criminal conviction, and that many are able to recite additional crimes they have committed when they believe it is in their self-interest to do so.     

An Examination of Triarchic Psychopathy Constructs in Female Offenders

This study sought to expand scientific knowledge on psychopathic personality traits in female offenders by evaluating the relationship between MMPI–2–RF triarchic scales and self-reported external variables in a sample of 205 female offenders. Results indicated that boldness was inversely related to internalizing dysfunction, including suicidal behavior, psychosis, youth conduct problems, problems stemming from alcohol use, and a history of outpatient mental health treatment. Meanness was positively related to internalizing dysfunction as well as youth conduct problems, anger, prison disciplinary reports, and psychosis. Disinhibition was associated with a history of abuse in childhood, suicidal behavior, internalizing dysfunction, problems associated with alcohol and drug use, family history of mental illness, prison disciplinary reports for violence, number of previous criminal charges, and anger. Consistent with views of psychopathy as a configural condition, interactive effects of boldness with disinhibition and meanness were observed for multiple key external variables (e.g., conduct problems, substance use, nonsuicidal self-injurious behavior). This study provides further evidence for the triarchic conceptualization of psychopathy in female offenders and lends additional support for the validity of MMPI–2–RF triarchic psychopathy scales.     

Gender differences in comorbid disorders among offenders in prison substance abuse treatment programs

This study examined gender differences in a range of lifetime psychiatric disorders in a sample of 272 offenders newly admitted to a prison substance abuse program. Although these men and women did not differ in severity of substance use in the six months prior to incarceration, women were significantly more likely than men to report a lifetime psychiatric disorder and a lifetime severe disorder. Furthermore, gender differences emerged in the pattern of lifetime psychiatric comorbidity. Women reported greater lifetime major depression, posttraumatic stress disorder, eating disorder, and borderline personality disorder; men were more likely than women to meet criteria for antisocial personality disorder. Additionally, female offenders were found to have a higher degree of internalizing disorders than male offenders, but there were no gender differences in degree of externalizing disorders. The study concluded that women offenders newly admitted to a prison substance abuse program present with a greater psychiatric vulnerability and a different pattern of psychiatric comorbidity than their male counterparts.     

Apology in the criminal justice setting: evidence for including apology as an additional component in the legal system

The criminal justice system has reached unprecedented scope in the United States, with over 6.4 million people under some type of supervision. Remedies that have the potential to reduce this number are continually being sought. This article analyzes an innovative strategy currently being reconsidered in criminal justice: the apology. Despite a legal system that only sporadically acknowledges it, evidence for the use of apology is supported by social science research, current criminal justice theories, case law, and empirical studies. Social psychological, sociological and socio-legal studies pinpoint the elements and function of apology, what makes apologies effective, and concerns about apology if it were implemented in the criminal justice system. Theoretical evidence is examined (including restorative justice, therapeutic jurisprudence, crime, shame, and reintegration) to explore the process of apology in the criminal justice context. Attribution theory and social conduct theory are used to explain the apology process specifically for victims and offenders. A brief examination of case law reveals that though apology has no formal place in criminal law, it has surfaced recently under the federal sentencing guidelines. Finally, empirical evidence in criminal justice settings reveals that offenders want to apologize and victims desire an apology. Moreover, by directly addressing the harmful act, apology may be the link to reduced recidivism for offenders, as well as empowerment for victims. This evidence combined suggests that apology is worthy of further study as a potentially valuable addition to the criminal justice process.     

Technological advances in the assessment of impulse control in offenders: A systematic review

Deficits in impulse control have been linked to criminal offending, risk of recidivism, and other maladaptive behaviours relevant to the criminal justice system (e.g. substance use). Impulse control can be conceptualized as encompassing the broad domains of response inhibition and impulsive/risky decision‐making. Advancements in technology have led to the development of computerized behavioural measures to assess performance in these domains, such as go/no‐go and delay discounting tasks. Despite a relatively large literature examining these tasks in offenders, findings are not universally consistent. This systematic review aims to synthesize the literature using computerized neurocognitive tasks to assess two domains of impulse control in offenders: response inhibition and impulsive/risky decision‐making. The review included 28 studies from diverse geographic locations, settings, and offender populations. The results largely support the general conclusion that offenders exhibit deficits in impulse control compared with non‐offenders, with studies of response inhibition more consistently reporting differences than studies using impulsive and risky decision‐making tasks. Findings are discussed in the context of contemporary neuroimaging research emphasizing dysfunction in prefrontal cortex as a key contributor to impulse control deficits in offenders.     

Designated as Dangerous: Characteristics of Sex Offenders Subject to Post‐Sentence Orders in Australia

The earliest characterisation of Australian sex offenders subjected to post‐sentence legislation is presented. Demographic, developmental, clinical, and criminal characteristics were obtained for sex offenders under post‐sentence orders in Western Australia, New South Wales, and Victoria. Data on 50 offenders were recorded from psychological and psychiatric risk assessment reports statutorily required at the initiation of post‐sentence legal proceedings. The findings describe a group of demonstrably dangerous men who exhibited an early onset of sexual offending, high rates of mental disorder, sexual deviance, and antisociality. Their developmental histories are characterised by early deprivation, disadvantage, abuse, early exposure to substance abuse, and social and psychological dislocation. These offenders present a conundrum to criminal justice agencies. They are an objectively unfortunate group and have engaged in significantly harmful behaviours. However, the early onset of their offending suggests that early intervention services, such as those offered by mental health professionals, have a critically important role to play in any effort to alter offending trajectories such as those exhibited in this sample. A paradigm shift in public policy from a post hoc model to a well‐resourced preventative and public health approach to the problem of sexual violence is proposed. Broad treatment implications are also considered.     

An examination of the effects of mental disorders as mitigating factors on capital sentencing outcomes

Mentally ill and emotionally disturbed offenders comprise a significant component of those whose criminal conduct has swept them into the criminal justice system, including a subset who are tried and convicted of capital murder. The present study employs the population of capital cases advanced to penalty phase in the state of North Carolina (1990–2009) to examine whether presentation to the jury of the statutory mitigators of extreme mental and emotional disturbance and capacity impaired, and specific mental illness diagnoses, often referred to as mental disorders, at the sentencing phase mitigate against a sentence of death. Mental disorders included mood disorders, psychotic disorders, anxiety disorders, brain disorders, multiple mental illness diagnoses, learning disabilities, and personality disorders. Results from these 835 cases indicate that with the exception of one, the diagnosis of a learning disability, the capital jury's acceptance of various mental health conditions does not effectively mitigate against a capital sentence. In addition, jury rejection of a diagnosis of mental illness or the two mental health statutory mitigators, capacity impaired and extreme emotional disturbance, as a mitigating factor has a counter-mitigating effect in that it significantly increases the odds of a death penalty recommendation by about 85–200%.     

A retrospective examination of outpatient commitment in New York

Outpatient commitment (OC) is a growing trend in mental health treatment. The impetus for this movement has been partly due to the public perception that some mentally ill outpatients are prone to violence as result of poor treatment compliance. Numerous studies have shown that poor treatment compliance is associated with increased hospitalization, substance abuse, homelessness, and contact with the criminal justice system. This study examined treatment effectiveness, demographic variables, hospital utilization, and violence among 100 OC participants in New York. Results indicate that OC can be an effective means of increasing treatment compliance and reducing hospitalization and encounters with the criminal justice system.     

Dual diagnosis in an Australian forensic psychiatric hospital: prevalence and implications for services

Despite a growing awareness of the unique needs of psychiatric patients with co-occurring substance abuse and dependence disorders (i.e. dual diagnosis), there is a dearth of research investigating the prevalence of dual diagnosis in forensic psychiatric populations. Similarly, little work has been done to determine the implications of dual diagnosis for forensic psychiatric patients. Patients at the Thomas Embling Hospital in Victoria, Australia, were assessed to determine the prevalence of substance abuse disorders and mental illnesses within this population. Results reveal that the majority of patients (approximately 74%) have a lifetime substance abuse or dependence disorder. Information was collected concerning patients' criminal histories and the Level of Service Inventory, Revised, was completed for each patient who participated. Results suggest that patients with both major mental illnesses and substance abuse disorders have more extensive criminal histories and demonstrate a higher level of risks and needs when compared with patients with major mental illness alone. The implications for the development and delivery of effective forensic mental health services that address both co-occurring disorders are also discussed.