Discussion

Treating Prison Inmates with Co-Occurring Disorders: An Integrative Review of Existing Programs

John F. Edens, Ph.D.,* Roger H. Peters, Ph.D., and Holly A. Hills, Ph.D.

The tremendous growth in state and federal correctional

populations has focused greater attention on the needs of

mentally ill and substance abusing inmates. Although an

estimated 3±11% of prison inmates have co-occurring

mental health (psychotic and major mood) disorders and

substance abuse disorders, few treatment programs are

described in the literature and there is little available

information regarding effective treatment strategies for

this population. The current study provides an integrative

review of seven `dual diagnosis' treatment programs that

recently have been developed in state and federal prisons.

Many of these have evolved from existing substance abuse

treatment programs and approaches. Key program

components include an extended assessment period,

orientation/motivational activities, psychoeducational

groups, cognitive±behavioral interventions such as

restructuring of `criminal thinking errors', self-help

groups, medication monitoring, relapse prevention, and

transition into institution or community-based aftercare

facilities. Many programs use therapeutic community

approaches that are modified to provide (a) greater

individual counseling and support, (b) less

confrontation, (c) smaller staff caseloads, and (d) cross-

training of staff. Research is underway in three of the

seven sites to examine the effectiveness of these new

programs. #1997 John Wiley & Sons, Ltd.

Behav. Sci. Law, Vol. 15, 439±457, 1997.

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Behavioral Sciences and the Law, Vol. 15, 439±457 (1997)

* Correspondence to: John F. Edens, Ph.D., Mental Health Law and Policy, The Florida Mental Health Institute, University of South Florida, 13301 Bruce B. Downs Boulevard, Tampa, Florida 33612-3899, USA. John F. Edens, Ph.D., and Roger H. Peters, Ph.D., Department of Mental Health Law & Policy, University of South Florida; Holly A. Hills, Ph.D., Department of Community Mental Health, University of South Florida. The authors would like to extend their thanks to the various program directors and program staff whose participation made this article possible: Marcia Baker (Hackberry SAFP), John Burns (Estelle SAFP), Redonna Chandler (Lexington), Merle Friesen, Dorothy Gieger, and Ernie Marshburn (Ventress), Kevin Hormann and Wendy Johnson (Turning Point), James Michaud and Joseph Stommel (San Carlos), and Craig Warrington (Chronic Care Program).

Rapidly escalating correctional populations throughout the country in the past 10

years have led to greater attention to the needs of inmates with mental health and

substance use disorders. Both state and federal corrections populations are

characterized by high rates of these disorders (General Accounting Office, 1991;

Keith, Regier, & Rae, 1992; Pepper & Massaro, 1992; Peters, Greenbaum, Edens,

Carter, & Ortiz, 1997). For example, state prison inmates have lifetime prevalence

rates of schizophrenia, major depression, and substance use disorders that greatly

exceed those detected in the community (Chiles, Von Cleve, Jemelka, & Trupin,

1990; Robins & Regier, 1991). Many prison inmates concurrently meet diagnostic

criteria for major mental health and substance use disorders. Approximately 26% of

substance abusing prison inmates have a lifetime history of major depression,

bipolar disorder, or atypical bipolar disorder, and 9% have a history of

schizophrenia (Cote & Hodgins, 1990). In the absence of specific

epidemiological findings, it is estimated that approximately 3±11% of prisoners

have co-occurring Axis I mental health disorders and substance use disorders

(Peters & Hills, 1993).

Individuals with co-occurring disorders present several unique challenges and

generally have a poor prognosis for involvement in treatment, relative to those

diagnosed with single disorders (McLellan, 1986; Weiss, 1992). In comparison to

others in treatment, individuals with co-occurring disorders have been shown to

experience (a) more rapid progression from initial use to drug dependence (Weiss,

Mirin, Griffin, & Michael, 1988), (b) poor medication compliance (Drake, Osher,

& Wallach, 1989), (c) decreased likelihood for successful completion of treatment

(Siddall & Conway, 1988; Zuckerman, Sola, Masters, & Angelone, 1975), (d)

higher rates of hospitalization and of suicidal behavior (Caton, 1981; Safer, 1987),

(e) and more rapid recurrence of symptoms following release from treatment

(Carpenter, Mulligan, Bader, & Meinzer, 1985; Kay, Kalathara, & Meinzer, 1989).

Within a criminal justice setting, individuals involved in jail substance abuse

treatment who have mental health symptoms have more pronounced difficulties

than other inmates in several areas of functioning, including employment, family

relationships, and medical problems, as well as lower baseline knowledge of

substance abuse treatment principles and relapse prevention skills (Peters, Kearns,

Murrin, & Dolente, 1992).

Several community-based treatment approaches have been developed in recent

years for persons with co-occurring disorders. These vary according to the

theoretical models and disciplinary orientation of the program. Programs emerging

from substance abuse treatment settings include therapeutic communities that have

been modified for co-occurring disorders (e.g., through use of psychoeducational

activities, less confrontation; Sacks & Sacks, 1995). These are highly structured

long-term residential substance abuse treatment programs that are typically staffed

by recovering individuals, focus on lifestyle and personality changes, and have strict

norms regarding participant behavior.

A number of recent studies conducted in community settings have demonstrated

long-term positive outcomes associated with treatment approaches for individuals

with co-occurring disorders. Jerrell and Ridgely (1995) examined a program that

included elements of a Social and Independent Living Skills (SILS) program

(Liberman, Massel, Mosk, & Wong, 1985) and a Behavioral Skills intervention

program, which was compared to intensive case management and 12-step recovery

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models. Participants in the SILS/Behavioral Skills program had significantly greater

improvement in work productivity, independent living skills, social adjustment, role

functioning, and social relations during followup. Co-occurring disorder treatment

programs integrating 12-step services and intensive case management have also

been examined in a seven-year followup (Bartels, Drake, & Wallach, 1995).

Approximately one quarter of participants with alcohol use disorders and a third of

those with drug use disorders achieved sustained abstinence during followup.

Although sample sizes in these studies are rather small, they provide preliminary

evidence of the potential effectiveness of integrated dual diagnosis treatment

approaches.

In recognition of the growing numbers of individuals with co-occurring disorders

in the justice system, several demonstration grant programs and collaborative

projects have been funded by the Center for Mental Health Services (CMHS), the

Center for Substance Abuse Treatment (CSAT), the National Institute of

Corrections (NIC), and the National Institute on Drug Abuse (NIDA). As an

example, the National GAINS Center (Gather, Assess, Interpret, Network,

Stimulate change) was established in 1995 through funding by CMHS, CSAT,

and NIC to assist in improving services for individuals with co-occurring disorders

in the justice system. There have also been advocates for development of

specialized `co-occurring disorder' treatment programs in criminal justice settings

(Pepper & Massaro, 1992; Peters et al., 1992) and for diversion of the mentally ill

and substance abusers from these settings (American Bar Association, 1992;

National Institute on Corrections, 1991; State Justice Institute, 1991; Steadman,

1991; Steadman, McCarty, & Morrissey, 1989).

Despite the growing population of prisoners with co-occurring disorders and

the awareness of the unique treatment needs of this population, the research

literature includes few descriptions of `dual diagnosis' treatment programs in

prisons. A recent survey of state and federal prisons identified only two treatment

programs designed specifically for individuals with co-occurring disorders (Peters

& Hills, 1993). Several other state correctional systems reported that they were

developing similar programs. The same survey found that only three states had

systematic procedures for identifying or tracking prison inmates with co-occurring

disorders.

This review describes current treatment initiatives in state and federal prisons

for inmates with co-occurring disorders and illustrates current trends in

providing services for this population. Goals of the review are to provide

guidelines for the implementation of prison-based dual diagnosis treatment

programs and suggestions for the adaptation of services for inmates with co-

occurring disorders within existing substance abuse or mental health treatment

settings. Key components of prison-based dual diagnosis programs are

highlighted, in efforts to identify common elements and innovative strategies

and approaches to working with this population. Specific program components

reviewed include the following: (a) program admission procedures, (b) treatment

strategies and special program adaptations provided for this population, (c)

program staffing, (d) coordination and linkage with other prison services and

reentry/aftercare services in the community, and (e) program evaluation. Several

common obstacles to effective treatment of co-occurring disorders in prisons are

also described.

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SURVEY PROCEDURES

Programs in this review include two described in a previous survey (Peters & Hills,

1993), those subsequently identified by the National GAINS Center, and programs

identified through correspondence and personal communications with correctional

treatment staff and administrators. Ten programs were initially identified.

However, one program that was previously operated by the South Carolina

Department of Corrections has been discontinued. Another program being

developed by the Florida Department of Corrections is scheduled to begin

operation in mid-1997 and has not begun admitting inmates. A third program, the

Mental Health-Corrections Outreach Intensive Program (M-COIT) in Michigan

provides primarily post-release services such as case management, advocacy,

outreach, specialized dual diagnosis treatment, and vocational counseling and

rehabilitation (Conklin, 1996).

Once the prison programs were identified, information regarding the remaining

seven programs was obtained from structured telephone interviews conducted with

program coordinators and treatment staff. Structured interviews were

approximately 90±120 minutes in duration. Programs described in this report are

located in a federal prison and in six state prisons in different states. Two of the

state prison programs serve felony probationers and parole violators.

PROGRAM DESCRIPTIONS

Dual Diagnosis Unit, Ventress Correctional Facility (Alabama)

This 62-bed program for male inmates is contained within a prison designated

exclusively for substance abuse treatment. The program has been in operation since

1992, and was developed due to increased staff awareness that inmates with co-

occurring mental health disorders were less successful in completing the substance

abuse treatment program. Although serving as a separate unit within the prison,

participants in the dual diagnosis program have frequent interaction with inmates

in substance abuse units. Inmates typically are treated during their last year of

incarceration.

Approximately 60±70% of inmates admitted to the program are diagnosed with

chronic depressive disorders, 10% are diagnosed with schizophrenia, and 15% are

diagnosed with bipolar disorder. Inmates receive approximately 25 to 30 hours

per week of treatment and educational programming during the course of the 15

week program. Treatment services consist primarily of group activities, and

incorporate 12-step principles, psychoeducational components, and relapse

prevention approaches. Core treatment services are similar to those provided to

other inmates in substance abuse treatment but are augmented to address the

special needs of inmates with co-occurring disorders. Given the high rate of

depressive disorders, staff incorporate several psychoeducational classes that

specifically address the management of depressive symptoms, the effects of

substance abuse on depression and other mood disorders, and the importance of

medication maintenance. The dual diagnosis unit is staffed by two full-time

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counselors, a half-time master's level supervisor, and receives consultation from a

psychologist and psychiatrist on a part-time basis. Medical and psychiatric

nursing services also are available on a 24-hour basis through the prison's medical

service.

Crisis Care Unit, Sussex Correctional Institution (Delaware)

Inmates with co-occurring disorders in the Delaware correctional system are

referred for treatment to the Crisis Care Unit, a 40-bed unit located in the

maximum security Sussex Correctional Institution. Although this program was

originally designed for mentally retarded and mentally ill inmates, specialized

services for inmates with co-occurring disorders were developed as greater

numbers of substance abusers were placed in this program. Approximately 75%

of inmates presently have both a chronic mental illness (primarily schizophrenia)

and a substance abuse diagnosis. The program has recently contracted with a

new service provider, Prison Health Services, Inc., and has become more

focused on stabilization of inmates with severe psychiatric conditions rather than

on long-term treatment. A new policy and procedures manual is currently in

preparation.

The length of treatment currently averages from two to three months, although

some inmates with more chronic impairment may remain in treatment for the

duration of their sentence. Treatment services are provided seven days a week by a

mental health counselor, activity therapist, correctional counselor, and a consulting

psychiatrist. The program includes a comprehensive psychosocial assessment,

individual and group therapy, medication monitoring, psychoeducational groups,

relapse prevention, recreational therapy, and individual case management.

Behavioral reinforcement is provided by the program through use of a level

system, in which inmates progress to higher levels of responsibility and privileges

based on compliance with treatment goals and community rules and regulations.

Although the Crisis Care Unit is separated from other institutional programs,

inmates share meals, recreation yard, and religious activities with other inmates.

Turning Point Alcohol and Drug Program: Columbia River Correctional Institution (Oregon)

This 50-bed therapeutic community for women is operated by ASAP Treatment

Services, Inc., and is housed in a 500-bed minimum security state prison for female

and male inmates. The program was initiated in 1990 through a grant from CSAT,

although the program is now supported entirely by the Oregon Department of

Corrections. The program is housed separately from the main prison population

and serves as a pre-release institution for female inmates. The program provides a

five-phased treatment program of six to 15 months duration, contingent upon

inmates' release dates, with a seven to eight month average.

Originally conceptualized as a substance abuse treatment program, mental health

services gradually became included due to the high rates of inmate dropout which

were attributed to untreated Axis I mental health disorders. Approximately 60% of

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inmates in the program are dually diagnosed, including approximately 70% with

post traumatic stress disorder (PTSD), 50% with depression, and 15% with bipolar

disorder. The high rate of PTSD is attributed by staff to a history of physical and/or

sexual abuse that is reported by a majority of the female inmates. Relatively few

inmates (2±5%) are diagnosed with psychotic-spectrum disorders. A minimum of

30 hours of treatment and educational services are provided each week. Treatment

services are oriented towards group sessions, and incorporate substance abuse

education, life skills, and relapse prevention strategies within a therapeutic

community environment. Specific groups for physical and sexual abuse survivors

also are provided for inmates.

The program is staffed by 10 counselors who have different areas of expertise in

assessment, family therapy, milieu therapy, mental health counseling, and primary

and ``transitional'' counseling. Although staff have varying educational backgrounds,

all are certified alcohol and drug counselors (CADCs), in accordance with new

Oregon certification requirements. Four other staff positions (nurse practitioner,

psychiatric nurse practitioner, mental health case manager, and licensed professional

counselor) are provided through the institution's health services department, in

addition to consultation from other psychiatric and medical staff.

Dual Diagnosis Track, Lexington Federal Medical Center (Kentucky)

This is program was designed for 16 male inmates within a 120-bed substance

abuse treatment unit in a large federal prison for inmates with special medical

needs. The dual diagnosis program has been in operation since 1996. The majority

of inmates are diagnosed with major mood or psychotic-spectrum disorders,

although inmates with severe anxiety disorders are also considered for admission.

Inmates typically must be within 36 months of their release date before they will be

considered for admission into the program, which maintains an extensive waiting

list.

Inmates receive approximately 20 hours per week of treatment during the course

of the nine-month program, which consists of three 12-week phases. The program

uses a biopsychosocial model of recovery that incorporates psychoeducational,

cognitive, and relapse prevention approaches in a community environment. In

addition to participation in core program services provided to inmates in the larger

substance abuse unit, inmates with co-occurring disorders are provided specialized

process and educational groups designed to address mental health and co-occurring

disorder issues. Weekly individual therapy sessions and medication compliance

monitoring are also provided.

Two master's level staff serve as primary counselors for the dual diagnosis

program, although inmates interact with several other staff assigned to the larger

substance abuse program. Psychiatric services are provided once weekly through

the institution's mental health unit, where inmates may be referred if they

decompensate during treatment.

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Substance Abuse Felony Punishment Facility-TDCJ Estelle Unit (Texas)

This program provides 130 beds for `special needs' inmates within a 175-bed

modified therapeutic community operated by the Gateway Foundation for the

Texas Department of Criminal Justice (TDCJ). The program was developed as a

result of a large-scale expansion of substance abuse treatment within the state

corrections system, beginning in 1991, which included development of Substance

Abuse Felony Punishment Facilities (SAFPs). The Estelle Unit was developed in

1994, following determination that the needs of individuals with co-occurring

disorders were not being adequately addressed in existing SAFPs. The program was

initially funded through a CSAT demonstration grant but is expected to be entirely

supported by TDCJ in the near future.

Approximately 50±60% of `special needs' inmates have a major mental health

disorder, while the remaining inmates have various medical conditions. Individuals

with severe mental health disorders are given priority for admission. Approximately

40±50% of participants with co-occurring disorders are diagnosed with a major

mood disorder, and 20±25% of participants are diagnosed with schizophrenia. The

three-phased program includes a minimum of 20 hours per week of treatment and

education services over a period of nine to 12 months. Treatment is provided

primarily in groups, and incorporates 12-step principles, chemical dependency

education, and relapse prevention strategies within a therapeutic community

setting.

The program is staffed by two master's level clinical supervisors and 11

counselors, all of whom have completed or are in the process of achieving licensure

in chemical dependency counseling (LCDC). Five nurses and a part-time

psychiatrist also provide services to the program. Although housed in a prison,

the program serves felony probationers and parole violators.

Substance Abuse Felony Punishment Facility-TDCJ Hackberry Unit (Texas)

This 288-bed program is operated by Phoenix House of Texas, Inc., and provides

treatment for women with substance use disorders who are also either pregnant or

have developmental disabilities, chronic medical problems, or Axis I mental health

disorders. Approximately 55% of inmates have a major mental health disorder in

combination with a substance use disorder. The most frequent mental health

diagnoses received by participants are major depression (22%) bipolar disorder

(16%), psychotic-spectrum disorders (13%) and anxiety disorders (5%). The dual

disorders treatment track consists of three phases, and lasts from nine to 12

months.

The program is based on a modified therapeutic community approach that

incorporates psychoeducational programs, women's issues, Alcoholics Anonymous,

process groups, and relapse prevention activities. Treatment is provided primarily

in groups, although individual counseling is also available. Inmates with co-

occurring disorders participate both in encounter groups with other special needs

inmates and in groups addressing specialized dual diagnosis topics. As with the

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Estelle program, the Hackberry program provides services for felony probationers

and parole violators. As part of their conditions of probation or parole, participants

in these programs are sentenced to participate in treatment programs that are

located within correctional facilities.

Dual Diagnosis Unit, San Carlos Correctional Facility (Colorado)

The dual diagnosis program is a 32-bed unit within the 250-bed San Carlos

Correctional Facility, which serves inmates with `special needs'. The program

opened in 1995 and is a modified therapeutic community that provides

psychoeducational, life skills training, and cognitive±behavioral interventions.

Approximately 30±40% of inmates have a psychotic-spectrum disorder and

receive priority admission into the program; approximately 50% of inmates have a

major depressive disorder. The San Carlos program is located in a pre-release facility

in a mixed custody setting. Inmates typically spend eight hours a day in treatment,

educational programs, and work activities within the therapeutic community.

Although the intended program length is approximately 12 months, the duration of

treatment is determined by release decisions made by the parole board.

The dual diagnosis program is jointly staffed by addiction counselors from

Addiction Recovery Programs, Inc., and by mental health and correctional staff

from the Colorado Department of Corrections. Staff include two full-time and one

half-time Certified Addictions Counselors (CACs), a part-time psychologist and

psychiatrist, a social worker, nursing staff, and corrections staff. As part of an

ongoing research and technical assistance grant from NIDA, the program is

expected to expand from 32 to 64 beds in the near future.

KEY ELEMENTS OF CORRECTIONAL TREATMENT PROGRAMS

The following section describes major components of treatment services provided

for prison inmates with co-occurring disorders. Findings from the survey of

correctional programs are summarized to identify common approaches, innovative

strategies, and key issues faced by correctional programs in implementing co-

occurring disorder treatment programs.

Program Admission

Referral and screening

Inmates are usually referred to treatment in three ways: (a) after completion of

screening at a prison intake/reception facility, (b) after referral to either a substance

abuse or mental health treatment program, or (c) after identification of symptoms

while placed in the general population. For the Estelle and Hackberry programs,

screening occurs in the counties in which the probation and parole violators are

adjudicated.

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The method and intensity of screening procedures varies across the prison

programs surveyed, although most use some combination of diagnostic interview

and self-report instruments that address both substance abuse and mental health

symptoms. Commonly used screening instruments and approaches include the

MMPI-2, MCMI-II, Level of Supervision Inventory (LSI), cognitive and/or

academic screening measures such as the Beta IQ and Wide Range Achievement

Test, diagnostic interviews conducted by psychologists or psychiatrists, extensive

psychosocial histories, and self-report drug history questionnaires. Most screening

for co-occurring disorder programs is conducted or supervised by doctoral-level

staff and may be accompanied by review from an `evaluation team'.

Admission criteria

Admission criteria vary considerably across the different co-occurring disorder

programs. Most programs have taken steps to disseminate information regarding

admission criteria to potential referral sources (judges, reception center staff, prison

wardens, and psychology and psychiatry staff) in order to minimize inappropriate

transfers. Diagnosis of a DSM substance use diagnosis, coupled with a DSM

mental health disorder (e.g., schizophrenia, major depression, or bipolar disorder)

usually is required for admission. Although most program participants have major

mental health and substance use disorders, there is a broad range of functional

impairment among participants. The Lexington program also requires justification

from referral sources that an inmate cannot receive adequate treatment in another

substance abuse or mental health program prior to being transferred to their

facility.

Some prison programs' admission criteria are rather broad, requiring only a

history of mental health treatment or psychotropic medication use in combination

with a history of substance abuse in the last year. Others, such as the Ventress

program, develop referral decisions on the basis of the evaluation team's

determination of whether an inmate might benefit from treatment rather than

relying on formal admission criteria. In the Turning Point program, referral

decisions are sometimes based on inmates' requests for treatment services even if

these individuals do not meet defined diagnostic criteria.

Several common exclusionary criteria are used to screen out inmates who are

unlikely to benefit from treatment. These include restrictions based on (a) the

assigned security level of the facility where the program is located (e.g., minimum

security); (b) the severity of medical problems, physical disabilities, or cognitive

impairments; and (c) the severity of psychiatric impairments exhibited, such as

acute symptoms, behavioral problems, or difficulty in achieving stabilization on

psychotropic medication. Inmates in the latter group are sometimes accepted for

admission if it is anticipated that they can be stabilized within a short period of

time. Inmates typically are not excluded from dual disorders treatment programs

unless they express active psychotic symptoms that are disruptive to program

activities or that require consistent staff attention. According to program staff at

most sites, exclusions based on psychotic symptoms occur infrequently. Other than

the Crisis Care Unit, however, few programs surveyed have on-site stabilization

beds available for inmates who are actively psychotic at the time of admission or

who decompensate during the course of treatment. Under these circumstances,

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most programs initiate transfer to specialized mental health units pursuant to

stabilization, at which time they can be reconsidered for program admission.

Assessment

All programs surveyed included an intensive initial period of assessment. During

this period, prior diagnoses are usually reevaluated, structured assessment

instruments and interviews are conducted, medication evaluation is provided,

case managers are assigned, and treatment plans are developed. Typical

assessment methods and instruments include the MMPI-2, the MCMI-II, the

Addiction Severity Index (ASI), the Symptom Checklist-90, diagnostic interviews

conducted by psychologists or psychiatrists, extensive psychosocial and criminal

histories, self-report drug history questionnaires, and various cognitive and/or

academic screening measures used to determine inmates' abilities to effectively

comprehend the services being provided.

Correctional treatment programs differ widely in their use of standardized

assessment and objective diagnostic instruments. For example, the Estelle program

places considerable emphasis on standardized testing, while programs such as

Ventress view this as a relatively inefficient use of staff resources. These different

approaches may reflect the diagnostic heterogeneity of inmates served in the

programs, as well as in the perceived quality and accuracy of initial screenings that

have been conducted. One unique assessment approach used in the Hackberry

program involves use of Global Assessment of Functioning (GAF) scores from the

DSM-IV to place inmates into treatment groups with other inmates at similar levels

of psychosocial functioning. Inmates are placed into one of three levels of

encounter groups based on these scores, which are then used as repeated measures

to assess progress during involvement in the program.

Common Problems in Screening and Assessing Inmates with Co-Occurring Disorders

Screening, referral, and assessment procedures are often complicated due to the

complex interaction of substance use and mental health symptoms. Many co-

occurring disorders are not identified because their symptoms are not detected

during initial screening. These individuals are often placed in mental health or

substance abuse programs due to attribution of co-occurring symptoms to the

disorder that was originally identified. This problem is accentuated by inmates'

reluctance to provide accurate disclosure of their substance abuse history at the

time of admission screening. Another common problem is that inmates may be

mistakenly referred to co-occurring disorder programs because their withdrawal

symptoms mimic major mental health disorders. Due to the complexity of

symptom interaction and the need for an extended baseline assessment (Peters &

Hills, 1993), many initial diagnoses formulated by screening staff are treated as

provisional by staff in dual diagnosis programs.

Use of `gain time' (i.e., reductions in sentence length) as an incentive for

substance abusers to enter treatment also tends to complicate the screening and

assessment process. Under these conditions, many inmates without co-occurring

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disorders will feign or exaggerate mental health and/or substance abuse symptoms

in order to gain admission to treatment. Other inmates will attempt to gain

admission to impress parole boards of their efforts towards `rehabilitation'.

Treatment Interventions, Approaches, and Modifications

Although the prison treatment programs differ somewhat in philosophy and type of

interventions, all endorse the importance of a strong community atmosphere and

include psychoeducational, 12-step, cognitive±behavioral, and relapse prevention

strategies. Several common goals of treatment programs include (a) providing a

highly structured therapeutic environment, (b) destigmatizing mental illness, (c)

focusing on symptom `management' rather than `cure', (d) education regarding

individual diagnoses and the interactive effects of co-occurring disorders, (e)

restructuring inmates' criminal `thinking errors', and (f) developing basic life

management and problem-solving skills. Although all programs provide more

individual case management and counseling than is typically available in substance

abuse programs, the primary treatment modality is group therapy. Specific types of

interventions used include peer-led encounter groups, 'process' groups, 12-step

groups (e.g., Alcoholics Anonymous, Emotions Anonymous), family therapy,

individual case management, behavior modification, cognitive±behavior therapy,

and various psychoeducational groups. Topics of psychoeducational groups

typically address responsible use of medication, mental and physical health

consequences of drug use, symptom interaction of co-occurring disorders, AIDS/

HIV awareness, and life management skills. Dual diagnosis programs for female

inmates at Turning Point and the Hackberry Unit also address specialized topics

such as sexual abuse and trauma, and parenting and relationship skills.

Phases of Treatment

Each program uses a highly structured approach in treating inmates with co-

occurring disorders. Several programs provide specific phases of treatment, usually

consisting of an initial assessment and orientation period, an intensive treatment

phase, and a relapse prevention/transition phase. Programs that do not provide

specific treatment phases still incorporate these three basic components, even

through phases may not be as clearly demarcated. Some programs follow specific

time frames for program length and require completion of all treatment phases for

graduation, whereas other programs have adopted a more flexible approach

regarding length of treatment and criteria for completion.

Orientation

Given the functional limitations of many inmates with co-occurring disorders and

their increased need for structure, a strong emphasis is placed on orientation to

program goals, expectations, rules and guidelines, and to treatment activities in

preparation for their involvement in treatment. The orientation phase usually

consists of a thorough assessment of substance abuse and mental health history and

current symptoms; a review of program policies, rules, and procedures; an

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introduction to the recovery process; assignment of a case manager; and

development of a treatment plan or contract. Programs such as Turning Point

incorporate information from behavior logs maintained by correctional and

treatment staff in developing treatment plans, and require successful completion

of exams before moving to the next phase of treatment. Most programs use the

orientation phase for assessment and development of motivation for treatment. For

example, inmates in the Lexington program complete a `readiness statement'

before moving to the next phase of treatment in order to foster a commitment to

change, while inmates in the Hackberry program begin each day during orientation

with a morning `motivational meeting'.

Intensive treatment

This second phase of treatment usually consists of 20 to 35 hours of individual and

group treatment and education per week, and involves a broad array of cognitive,

emotional, and behavioral interventions. Inmates typically are given homework

assignments and sometimes are tested on materials presented in psychoeducational

groups before being moved into the next phase of treatment. Treatment activities

may be provided with other inmates who do not have co-occurring disorders. In the

Lexington and Hackberry programs, which are embedded within larger substance

abuse programs, participants complete the same `core' treatment activities as other

inmates with only substance abuse diagnoses, but also are involved in a special dual

diagnosis track. Rather than having specific programs or classes for inmates with

co-occurring disorders, all inmates in the Estelle program participate in the same

core activities to encourage a community atmosphere and to destigmatize mental

and physical disorders. All inmates in the program are involved in treatment

activities related to mental illness, co-occurring disorders, physical disabilities and

disorders, and medication management.

Relapse prevention/transition

Relapse prevention principles and strategies usually are addressed in this phase of

treatment. Activities include education regarding the relapse process; identification

of relapse cues, triggers, and warning signs; understanding the role of medication

compliance in preventing relapse; and development of a relapse prevention or

`contingency' plan. Some programs use materials and workbooks designed

specifically for criminal justice populations (Gorski, 1989), whereas others have

developed their own materials and procedures. The length of this treatment phase

and the requirements for successful completion vary across programs. Several

programs employ `transitional coordinators' or other case managers to facilitate

aftercare and linkage with other services during this phase of treatment.

Program Modifications for Inmates with Co-Occurring Disorders

Many adaptations or changes in traditional treatment approaches are necessary

when working with inmates with co-occurring disorders. These include several

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modifications to the content, format, intensity, and duration of interventions, as

described in the following section.

. Smaller caseloads: Counselors who work with inmates who have co-occurring

disorders often have smaller caseloads than other counselors in order to

provide more individualized counseling or case management services.

. Shortening and simplifying meetings: Due to the attenuated cognitive abilities of

some inmates with co-occurring disorders, programs typically shorten and

simplify psychoeducational classes. In addition, there is increased repetition of

material in order to foster better comprehension.

. Addressing `criminal thinking': Specific interventions are provided for inmates

who have developed an ingrained pattern of criminal thinking and values.

These include adapting cognitive±behavioral strategies (e.g., Rational Emotive

Therapy, Rational Behavior Therapy) for self-assessment and restructuring of

criminal thinking patterns and examination of the relationship between

irrational thoughts, criminal behavior, and drug use. For example, criminal

`thinking errors' (Yochelson & Samenow, 1976, 1986) are sometimes

conceptualized as potential relapse cues or triggers for a return to drug use

and/or a criminal lifestyle.

. Medication education: Programs attempt to educate inmates with co-occurring

disorders about the importance of medication compliance, potential side

effects, and strategies for adapting to new medications. For programs that

blend inmates with co-occurring and single disorders, it is important to

educate inmates regarding the difference between useful and harmful drugs.

Some inmates (as well as staff) who have histories of substance abuse may

believe that the use of any drug is countertherapeutic and may discourage

inmates with co-occurring disorders from complying with needed

psychotropic medications.

. Minimizing confrontation: Although confrontation by peers is a primary

method of intervention in many substance abuse treatment communities,

inmates with co-occurring disorders are often less able to tolerate the

interpersonal stress and/or emotional arousal evoked by such encounters

(McLaughlin & Pepper, 1991; Sacks & Sacks, 1995). Co-occurring disorder

programs adopt a more supportive and educational approach in encounter

groups and provide treatment staff to supervise or coordinate group sessions in

which confrontation is likely to occur.

Staffing

Staff caseloads vary across the programs surveyed. Inmate-to-staff ratios ranged

from approximately 5±1 to 30±1. Given that many of the co-occurring disorder

programs evolved from substance abuse treatment programs, it is not surprising

that many program staff are certified or licensed chemical dependency counselors

who have varying degrees of specialized training in mental health and co-occurring

disorder treatment issues. Some programs are staffed by substance abuse

treatment counselors who have received additional training in mental health

issues and co-occurring disorders, while other programs have hired new personnel

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with educational backgrounds and/or work experience in both mental health and

substance abuse treatment. Programs typically employ clinical supervisors who

have at least master's degrees in clinical or counseling psychology or social work,

as well as specialized backgrounds or certification in substance abuse treatment.

Doctoral level psychologists typically are not assigned full-time to dual diagnosis

programs, but are usually available on a part-time basis to provide supervision and/

or direct services.

Arrangements to provide psychiatric and other medical services differ widely in

correctional co-occurring disorder programs. The Estelle program contracts with a

psychiatrist for services, while the Hackberry and Lexington programs rely on

internal psychiatric or medical staff for psychiatric evaluations and medication

monitoring. Other than the Crisis Care Unit, most programs indicate that they are

not equipped to treat inmates who decompensate for an extended period, and

usually transfer such inmates to specialized psychiatric facilities for acute care and

stabilization services. Within the San Carlos and Lexington programs, this process

often involves temporary transfer to another unit or building within the institution,

whereas for other programs this may involve transporting an inmate to another

facility.

Problems related to staffing correctional co-occurring disorder programs

sometimes result from the heterogeneous backgrounds of individual staff. For

example, correctional officers who are unfamiliar with symptoms and behaviors

associated with co-occurring disorders may adopt a more punitive or hostile

approach toward inmates who engage in unusual or disruptive behavior. Staff may

also disagree regarding the need for or appropriate dosage of various psychotropic

medications, particularly anti-anxiety medications such as benzodiazepines.

Philosophical differences among staff from mental health or substance abuse

backgrounds (i.e., related to medical vs. self-help models of treatment), as well as

the increased potential of inmates with co-occurring disorders to misuse

psychotropic medication (Drake et al., 1989), may increase the likelihood of

disagreements regarding medication issues. The Ventress program, for example,

traces its separation from adjacent substance abuse treatment units to ongoing

resistance from substance abuse staff to the use of psychotropic medications.

Aftercare/Linkage

All programs reviewed have procedures for transitioning inmates from treatment

into aftercare services. The type of aftercare services available following completion

of treatment ranges from services provided in another prison facility while the

duration of sentence is served; enrollment in a transitional living center, work

release program, or halfway house; or direct release into the community. With the

exception of the Crisis Care Unit, inmates who are discharged prior to completion

of their sentence typically are not transferred directly into a general population

setting. Rather, they are often placed in therapeutic communities or in aftercare

dorms for inmates who have completed substance abuse treatment. Pre-release

programs usually include opportunities for transfer to halfway houses or

transitional centers and sometimes require placement in these transitional

settings. The Turning Point program contracts with several aftercare programs

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and provides funds for the first two months of aftercare treatment. The Estelle and

Hackberry programs also coordinate and fund placement in transitional facilities

through state agencies. Transportation to different aftercare facilities is also

coordinated by many of the programs surveyed.

As noted earlier, several programs employ `transitional coordinators' whose

primary responsibility is to identify and link inmates with other institutional or

community resources (e.g., mental health/mental retardation centers, Alcoholics

Anonymous groups) during the final weeks of the program. Other pre-release

services may include development of a service plan, coordination with case

managers from community agencies or halfway houses, and pre-release meetings

involving inmates and their newly assigned community case managers. All

programs that release inmates to community supervision programs provide

parole/supervision officers with an aftercare plan to be used during the period of

`conditional release'.

Given the difficulties in providing a comprehensive range of services for inmates

with co-occurring disorders, it is not surprising that there are often significant gaps

between specialized institutional services and those provided in the community.

Difficulties in coordinating or obtaining post-release services are often related to the

following:

. A significant lack of community resources (halfway houses, outpatient

treatment programs) for inmates returning to rural settings.

. Resistance among community agencies to providing services for persons with

criminal histories.

. The absence of mental health services or medication monitoring among many

community-based substance abuse programs.

. Lack of training and awareness of mental health issues among community

supervision officers.

. Resistance among ex-offenders to continued involvement in treatment,

following release from custody.

Due to difficulties in locating appropriate aftercare programs for program

participants, the Hackberry program is seeking funding to establish its own post-

release aftercare facilities that focus on the specific needs of individuals with co-

occurring disorders. The San Carlos program has recently obtained funds from

NIDA to develop its own community corrections treatment facility for inmates

graduating from the dual diagnosis program. The Turning Point program attempts

to involve family members in aftercare planning. Ongoing education in mental

health and co-occurring disorder issues among community supervision and

aftercare personnel is sometimes provided to enhance continuity of treatment

involvement for program graduates.

Program Evaluation

Research findings from treatment programs in community settings provide

preliminary evidence for the efficacy of integrated treatment approaches for

individuals with co-occurring disorders (Bartels et al., 1995; Jerrell & Ridgely,

1995). Common barriers to conducting comprehensive program evaluation

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research in prisons include the lack of adequate staff, resources, and appropriate

control samples. Although extensive controlled studies have not yet been

conducted in the settings described here, the programs are generally tracking

rates of program completion and recommitment to prison. Preliminary research

from the Turning Point program indicates that program completers are less likely to

be reincarcerated following release, in comparison to the general inmate population

(Field, 1995; Research Unit, Oregon Department of Corrections, 1996).

The San Carlos and Estelle programs are currently involved in CSAT or NIDA-

sponsored treatment outcome research projects. The Lexington program has

developed a collaborative arrangement with the University of Kentucky to track a

cohort of program graduates in the community and to examine factors influencing

treatment outcomes. Preliminary results from the Estelle Unit (von Sternberg,

1997) indicate high rates of treatment retention. Program graduates were also

found to have lower rates of criminal activity and drug use following treatment,

relative to a comparison group. Program participants in the Estelle program

performed as well as or better than cohorts from other therapeutic communities

across several different areas of functioning, and performed significantly better on

these measures than inmates from the general population. More comprehensive

and final results from these program evaluation projects should provide valuable

information regarding the effectiveness of several different correctional co-

occurring disorder treatment approaches, and will help guide the implementation

of new programs and services for inmates with co-occurring disorders. Other

research is needed to examine the differential effects of correctional co-occurring

disorder programs embedded within larger substance abuse or mental health units,

predictors of program retention and completion, and long-term effects of treatment

on criminal recidivism, use of health care services, and recurrence of symptoms.

DISCUSSION

A significant number of prison inmates have mental health and substance use

disorders. Although investigations of treatment approaches for individuals with co-

occurring disorders have been underway in the community for approximately a

decade, corrections-based programming for this population has begun in earnest

only in the last few years. This review describes some of these recent efforts and

illustrates the core features and common difficulties inherent in establishing and

operating prison-based dual diagnosis treatment programs. The majority of these

prison initiatives evolved from previously established substance abuse treatment

programs and as a result of increasing awareness that program participants with co-

occurring disorders did not respond favorably to traditional intervention methods.

Although many of the correctional dual diagnosis treatment programs have their

roots in substance abuse treatment, they all integrate key components of mental

health treatment (e.g., psychiatric consultation, medication education and

compliance groups, individual counseling).

Resulting program modifications in correctional settings have attempted to

match treatment interventions to the varying symptom patterns, cognitive styles,

and needs for enhanced support and monitoring that are common among

individuals with co-occurring disorders. These correctional programs offer a

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comprehensive array of services that address both the biological and psychosocial

aspects of co-occurring disorders. As in similar programs developed in the

community, prison-based interventions address the need for treatment over

relatively long periods of time; and, unlike many traditional mental health or

substance abuse programs, typically minimize the use of exclusionary program

admission criteria.

Screening and assessment strategies vary somewhat across the sites, with some

programs placing less emphasis on formal diagnostic and objective testing than is

customary in community-based programs. Correctional programs consistently

select inmates for treatment who are nearing the end of their sentence and accept

referrals from a variety of sources (e.g., reception centers, other institutions). Self-

referrals also may be accepted, sometimes in the absence of more rigorous

diagnostic criteria. All of the dual diagnosis treatment programs surveyed provide

services for inmates with major mental disorders, including the chronically mentally

ill. However, most programs are not equipped to treat individuals with florid and

disruptive psychotic symptoms until these symptoms have stabilized. Program

designs are consistent with those found in community settings for persons with dual

disorders, and are derived largely from models developed within substance abuse or

mental health treatment settings. All programs attempt to provide an integrated

treatment approach through employment of multidisciplinary staff and wide use of

external program consultants. Although community resources are often limited,

prison-based programs make determined efforts to arrange transitional treatment,

housing, and access to adjunctive services following release.

Overall, dual diagnosis treatment programs in prisons have adopted practices and

procedures that are consistent with clinical research conducted in community

settings. Given our knowledge of the course and severity of co-occurring disorders

and the extensive service needs of this population, the prison programs surveyed in

this review appear to include appropriate treatment components and intensity of

services. The common goals established by existing prison dual diagnosis programs

also appear to be consistent with those identified in the community research

literature, and include the following:

. Use of multidisciplinary staff, with a blend of mental health and substance

abuse training and experience.

. Consideration of both disorders as `primary'Ðalthough a simultaneous focus

is not necessarily provided within all interventions.

. Focus on individualized assessment of skill deficits and symptom severity.

. Utilization and integration of psychopharmacological interventions.

. Providing a long-term treatment focus, with an emphasis on phases of

intervention.

. Recognition that the need for treatment extends beyond the institution and

into the community.

. Acknowledgment of the integral role of self-help efforts.

Although preliminary reports are encouraging, an extensive research base

examining the efficacy of prison dual diagnosis treatment programs will not be

available for several years. Current research efforts should prove quite valuable in

determining the most useful types of treatment interventions for this population

and the long-term effects of prison dual diagnosis treatment.

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