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Integrated TC Treatment for Offenders with Co-Occurring Substance Abuse and Psychiatric Histories

I recently had the opportunity to present to Spectrum staff and criminal justice administrators in Georgia on prison TC treatment of co-occurring disorders (COD). The Georgia DOC is forward thinking and very interested in effective prison treatment and a strong supporter of Spectrum’s COD treatment approach.  I have taken this blog opportunity to share the Georgia presentation.

Historically, mental health and substance abuse treatment have been seen as separate entities with different procedures, professional orientations and certifications.  In recent years, there has been a growing realization that COD disorders that include both a mental health and substance abuse diagnoses are more the norm then the exception and the preferred treatment approach based on both research findings and best practices is to treat both at the same time in an integrated approach. Spectrum is a leader in this area and is a firm supporter of integrated treatment for co-occurring disorders, both in prison and the community.

Overall, about three-quarters of state prisoners with mental health issues also have substance abuse or dependence problems.  Their criminal histories are more severe when compared to inmates without mental health problems as demonstrated by a greater likelihood of having three or more incarcerations, using drugs and/or alcohol at the time of their offense, using drugs in the month prior to arrest, being physically and/or sexually abused in the past, being homeless prior to incarceration, and being injured and charged with rule infractions while incarcerated.

Research has shown exceedingly poor prognoses for untreated dually diagnosed offenders.  Some of the issues are poor adherence to medication that leads to shorter time in remission, along with greater likelihood of hospitalization and suicidal behavior.  An overriding COD difficulty is impaired social functioning that interferes with the process of trust formation and bonding necessary for learning social skills and positive mental health.  It is important to note that the therapeutic community (TC) is an especially powerful modality for dealing with social dysfunctions since its modus operandi is the formation of healthy community dynamics and social skills training that enable members to become productive community participants.

The Substance Abuse and Mental Health Services Administration (SAMSHA) has defined integrated treatment, as a research-proven model of treatment for people with serious mental illnesses and co-occurring substance use disorders.  SAMSHA explains that consumers receive combined treatment for mental illnesses and substance use disorders from the same practitioner or treatment team.  They receive one consistent message about treatment and recovery.

A landmark outcome study by my colleague Sacks and his team has shown that a Colorado prison TC for COD inmates significantly reduced illegal drug use, criminal activity and re-incarceration at 12 months post release.  Based upon the work of Sacks and others, the National Institute on Drug Abuse (NIDA) has certified the COD prison TC model as an “evidence-based treatment”.

SAMSHA has delineated seven principles for the practice of integrated treatment that Spectrum applies in all their prison COD TC programs:

Principle 1 - Mental health and substance abuse treatment are integrated to meet the needs of people with co-occurring disorders.

Principle 2 - Integrated treatment specialists are trained to treat both substance use disorders and serious mental illnesses.

Principle 3 - Co-occurring disorders are treated in a stage-wise fashion with different services provided at different stages.

Principle 4 - Motivational interventions are used to treat consumers in all stages, but especially in the persuasion stage.

Principle 5 - Substance abuse counseling, using a cognitive-behavioral approach, is used to treat consumers in the active treatment and   relapse prevention stages.

Principle 6 - Multiple formats for services are available, including individual, group, self-help, and family.

Principle 7 - Medication services are integrated and coordinated with psychosocial services.

Spectrum monitors the process and outcomes of all its programs including the prison TC for COD inmates.  I am currently working with colleagues to assemble articles for a special issue of the Psychiatric Rehabilitation Journal on “Co-Occurring Mental and Substance Use Disorders in the Criminal Justice System” where a summary the work of Spectrum in this area will be included along with summaries of Spectrum’s evaluation research.

Readers are invited to send in reactions and questions to me at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .  I also welcome suggestions for future blog topics.

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