Filling service gaps: Providing intensive treatment services for offenders

Making change happen in criminal justice settings: leveraging implementation science to improve mental health care

BACKGROUND

It is a constitutional right to receive health care, including mental health care, while incarcerated. Yet, even basic evidence-based mental health care practices have not been routinely integrated into criminal justice (CJ) settings. Strategies from implementation science, or the study of methods for integrating evidence-based practices into routine care, can accelerate uptake of established interventions within low-resource, high-need settings such as prisons and jails. However, most studies of mental health practices in CJ settings do not use implementation frameworks to guide efforts to integrate treatments, systematically select or report implementation strategies, or evaluate the effectiveness of strategies used.

CASE PRESENTATIONS

After introducing implementation science and articulating the rationale for its application within CJ settings, we provide two illustrative case examples of efforts to integrate mental health interventions within CJ settings. Each case example demonstrates how an implementation framework either was applied or could have been applied to promote intervention adoption. The first focuses on poor implementation of a mental health screener in a county jail, retrospectively highlighting how use of a determinants framework (e.g., the Consolidated Framework for Implementation Research [CFIR]) could help staff identify factors that led to the implementation failure. The second describes an investigator-initiated research study that used a process framework (the Exploration, Preparation, Implementation, Sustainment [EPIS] framework) to systematically investigate and document the factors that led to successful implementation of a psychotherapy group for survivors of sexual violence in a women's community corrections center. Both are presented in accessible language, as our goal is that this article can be used as a primer for justice health researchers, community partners, and correctional leadership who are unfamiliar with implementation science.

CONCLUSIONS

Scientific research on the application of implementation science to justice settings is growing, but lags behind the work done in health systems. Given the tremendous need for mental and behavioral health intervention across the full spectrum of justice settings, information on how to successfully implement evidence-based intervention and prevention efforts is sorely needed but possible to obtain with greater integration of knowledge from implementation science.

Probation Staff Attitudes Toward Substance Abuse Treatment and Evidence-Based Practices

Given the substantial need for and relatively low access to effective substance use disorder treatment for people on probation, it is critical to understand organizational and staff attitudes that may hinder or facilitate treatment linkage and willingness to adopt evidence-based practices. This study used survey data from a large county probation department to assess staff members' attitudes and perceptions regarding their organization's climate for innovation, role of substance use disorder treatment, support for evidence-based treatment, and organizational barriers to change. Probation staff were open to incorporating treatment into probation supervision, expressed support for rehabilitation models, and agreed that they would adopt innovations if required or they found them to be appealing. However, they expressed some concerns about the level of agency support for innovation and collaboration. Attitudes and perceptions varied by staff characteristics. Implications for expanding organizational change and adoption of evidence-based treatment practices in probation are discussed.

Return to illicit drug use post-incarceration among formerly incarcerated Black Americans

Aims

The number of drug dependent individuals incarcerated in the U.S. is exceptionally high, and reportedly 60 percent of incarcerated Black Americans have a substance abuse disorder. The purpose of this study was to identify factors associated with return to illicit drug use post-incarceration.

Methods

A cross-sectional study was conducted with 121 formerly incarcerated Black Americans in New York City to examine predictors of return to illicit drug use. Kaplan-Meier curves were generated on the outcome of time-to-drug use for various predictors and compared using the log-rank test. Cox proportional hazards models were used to identify significant predictors of return to illicit drug use post-incarceration.

Findings

Approximately 83 percent (n=100) of the participants reported a history of illicit drug use, not including participants who have only used marijuana. Out of 121 participants, 36 (29.8%) had used drugs within one day after release. By two weeks after release, half had used drugs. Gender and history of heroin use were significant predictors of time-to-drug use according to the log rank test.

Conclusions

The potential for immediate return to drug use among our sample suggests that discharge support programs that focus specifically on healthy decision-making among women and heroin users are especially critical.

The GAIN Short Screener (GSS) as a Predictor of Future Arrest or Incarceration Among Youth Presenting to Substance Use Disorder (SUD) Treatment

The National Institutes of Health (NIH) data harmonization project on existing measures (www.phenx.org) has recommended the Global Appraisal of Individual Needs (GAIN)—Short Screener (GSS) as one of the most reliable, valid, efficient, and inexpensive general behavioral health screeners to quickly identify people with internalizing and externalizing mental health disorders, substance use disorders, and crime/violence problems. The present study examined how well the four GSS screeners and their sum predict future arrest or incarceration among individuals entering treatment for a substance use disorder. Using a cross-validation design, a diverse sample of 6,815 youth with substance use disorders was split into a development sample and a validation sample. Overall, results found the GSS’s crime and violence screener (CVScr) and the substance disorder screener (SDScr) to be the two best predictors of arrest/incarceration within the 12 months following treatment intake. Additionally, we found that these screeners could be used to categorize individuals into three groups (low risk, moderate risk, high risk) and this simplified classification had good predictive validity (Area Under the Curve = 0.601). In sum, the GSS’s predictive validity was similar to other instruments that have been developed to predict risk for recidivism; however, the GSS takes only a fraction of the time to collect (ie, approximately 2–3 minutes for just these two screeners).

Criminal justice and alcohol treatment: results from a national sample

This study investigates the associations of recent criminal justice involvement with perceived need for alcohol treatment and alcohol treatment utilization, adjusting for demographic and clinical characteristics. We examined a national sample of adults with alcohol use disorders (N=4390) from the 2006 National Survey on Drug Use and Health. Almost 15% reported criminal justice involvement in the past year. Generalized logit models regressed perceived need for alcohol or drug treatment and past year treatment utilization (versus neither) on past year legal involvement, demographic, and clinical information. In general, results found stronger associations between frequency of criminal justice involvement for treatment utilization compared to perceived need for treatment alone. Treatment utilization was also associated with being on probation, arrests for drug possession/sale and driving under the influence but perceived need was not. Study results suggest opportunities for interventions to increase treatment rates or treatment need, a major correlate of treatment utilization.

Understanding the importance of organizational and system variables on addiction treatment services within criminal justice settings

NIDA's Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) is the primary vehicle for testing emerging treatment interventions and fostering adoption of evidence-based therapies in criminal justice settings. The papers in this issue of Drug and Alcohol Dependence use data from the CJ-DATS National Criminal Justice Treatment Practice Survey to explore the influence of organizational and system variables on access to addiction treatment and the types of services available within correctional settings. This essay provides context for the papers in this issue of Drug and Alcohol Dependence. Systems and organizational interventions that improve the delivery and quality of drug abuse treatment services are described and the potential to apply systems change thinking to addiction treatment services available in the criminal justice system is discussed. Each paper is described briefly. CJ-DATS is evolving to support research at the organizational and systems level that facilitates the implementation and sustainability of research-supported treatments and business practices in criminal justice settings.

Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis

OBJECTIVE TO BE ADDRESSED: The purpose of this study was to investigate the structural and organizational factors that contribute to the availability and increased capacity for substance abuse treatment programs in correctional settings. We used classification and regression tree statistical procedures to identify how multi-level data can explain the variability in availability and capacity of substance abuse treatment programs in jails and probation/parole offices.

METHODS

The data for this study combined the National Criminal Justice Treatment Practices (NCJTP) Survey and the 2000 Census. The NCJTP survey was a nationally representative sample of correctional administrators for jails and probation/parole agencies. The sample size included 295 substance abuse treatment programs that were classified according to the intensity of their services: high, medium, and low. The independent variables included jurisdictional-level structural variables, attributes of the correctional administrators, and program and service delivery characteristics of the correctional agency.

RESULTS

The two most important variables in predicting the availability of all three types of services were stronger working relationships with other organizations and the adoption of a standardized substance abuse screening tool by correctional agencies. For high and medium intensive programs, the capacity increased when an organizational learning strategy was used by administrators and the organization used a substance abuse screening tool. Implications on advancing treatment practices in correctional settings are discussed, including further work to test theories on how to better understand access to intensive treatment services. This study presents the first phase of understanding capacity-related issues regarding treatment programs offered in correctional settings.

Organizational-level correlates of the provision of detoxification services and medication-based treatments for substance abuse in correctional institutions

In recent years, there has been an increased examination of organizational-level innovation adoption in substance abuse treatment organizations. However, the majority of these studies have focused on community-based treatment centers. One understudied area of the substance abuse treatment system is correctional institutions. This study uses the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative's National Criminal Justice Treatment Practices (NCJTP) survey to examine the adoption of detoxification services and pharmacotherapies for the treatment of substance abuse across a nationally representative sample of correctional institutions (n=198). There were significant differences between jails and prisons in the percentage of organizations offering detoxification services and medications. Specifically, detoxification services were offered by 5% of prisons and 34% of jails; and, medications were offered by 6% of prisons and 32% of jails. Binary logistic regression models were used to examine the associations between these services and organizational characteristics, including context, resources, previously introduced practices, culture, and systems integration. Variables measuring organizational context and previously introduced practices were significant correlates of the provision of both detoxification services and medications. Multivariate results indicated that the differences between jails and prisons remained significant after controlling for other organizational factors. Although the adoption of detoxification services and pharmacotherapies may be a controversial topic for correctional institutions, these services have the potential to improve offender well-being and reduce public health risks associated with substance abuse.

Organizational context, systems change, and adopting treatment delivery systems in the criminal justice system

The correctional system does not include service provision as a primary goal, even though individuals in prison, jail, and on probation/parole have large unmet substance abuse treatment needs. In response to mandates in the U.S. Constitution for basic health care, services are provided for incarcerated offenders, but generally do not include substance abuse treatment. The system does little to extend any type of health care service to individuals in community settings. This leaves the majority of offenders (6 million under community supervision in the U.S.) basically unattended, even with substance abuse disorders that are four times greater than the general public. The challenge of adapting the correctional system to be part of an integrated service provision system - working in conjunction with the public and private community-based service delivery sector - has intrigued researchers and policy makers over the last two decades. A series of articles using data from the National Criminal Justice Treatment Practices survey have examined factors that influence the adoption of a myriad of substance abuse treatment services for offender populations in various settings. These articles explore the factors that affect adoption and implementation, and provide guidance on issues relevant to organizational change and a dual mission of correctional agencies to advance public safety and public health. This special issue of Drug and Alcohol Dependence is devoted to understanding organizational constructs and factors to improve health outcomes for offenders.

Competing values among criminal justice administrators: The importance of substance abuse treatment

This study applied latent class analysis (LCA) to examine heterogeneity in criminal justice administrators' attitudes toward the importance of substance abuse treatment relative to other programs and services commonly offered in criminal justice settings. The study used data collected from wardens, probation and/or parole administrators, and other justice administrators as part of the National Criminal Justice Treatment Practices survey (NCJTP), and includes both adult criminal and juvenile justice samples. Results of the LCA suggested that administrators fell into four different latent classes: (1) those who place a high importance on substance abuse treatment relative to other programs and services, (2) those who place equal importance on substance abuse treatment and other programs and services, (3) those who value other programs and services moderately more than substance abuse treatment, and (4) those who value other programs and services much more than substance abuse treatment. Latent class membership was in turn associated with the extent to which evidence-based substance abuse treatment practices were being used in the facilities, the region of the country in which the administrator worked, and attitudes toward rehabilitating drug-using offenders. The findings have implications for future research focused on the impact that administrators' attitudes have on service provision as well as the effectiveness of knowledge dissemination and diffusion models.