Introduction

Dual diagnosis or co-occurring disorder (COD) is a diagnosis of a co-existing mental health disorder (MHD) and substance use disorder (SUD).[1] While there are diagnostic criteria for both disorders separately, to date, there is no standardized definition of COD.[2] According to results from the 2016 National Survey on Drug Use and Health, 8.2 million adults had a diagnosis of a mental illness and a substance use disorder.[3] Among those 8.2 million individuals diagnosed with a COD, about 48 percent received some form of treatment but only an estimated 6.9 percent received mental health and substance use treatment.[4] Compared to the general population, individuals with a COD are at an increased risk for incarceration, and roughly two-thirds of incarcerated women have a COD.[5]

The connection between SUD and MHD has been well established. Those with a MHD have an increased risk of diagnosis of a SUD, compared to the general population.[6] In 2016, individuals with a MHD were much more likely to also be diagnosed with a SUD than those without a MHD. Specifically, 18.5 percent of those with a MHD also had a SUD, while only 5.4 percent of those without a MHD had a SUD.[7] CODs may arise because abuse of drugs can result in symptoms of mental illnesses, those with a mental illness may use alcohol or drugs to self-medicate, and SUDs and MHDs are caused by overlapping factors.[8]

Despite frequent comorbidity of SUDs and MHDs, treatment delivery and funding remain compartmentalized.[9] The complexity of those issues indicates a need for treatment that is integrated—addressing both issues together.[10] Treatment plans for inmates are most effective when they are comprehensive and collectively handle all diagnoses, and medication and behavioral therapies can help to concurrently treat SUDs and MHDs.[11] Unfortunately, screening processes in the justice system often do not adequately identify those with a COD, making it more difficult to link individuals to the appropriate care and treatment.[12]

Current Study

Illinois Criminal Justice Information Authority (ICJIA) researchers evaluated the Dual Diagnosis treatment program operated by WestCare Foundation (Illinois) at Logan Correctional Center for women in Illinois, which is funded through the agency’s federal Residential Substance Abuse Treatment funds. The program focuses specifically on women identified as having COD. This publication offers findings from the process evaluation of the Dual Diagnosis treatment program. Researchers sought to learn how the program operated, about the clients and their views on the program, and staff views of the program. Administrative data and staff and client interviews were collected and analyzed to answer the core research questions:

  • How did the program operate?
  • Who were the clients?
  • What did the clients and staff think of the program?
  • To what extent did the program reduce PTSD symptoms?
  • To what extent did the program reduce aggression?

Program Operations

The Dual Diagnosis program at Logan Correctional Center is a residential, mental health and substance abuse treatment program, housing up to 26 women in a highly structured environment separate from the general prison population. The program has been in operation since August 2015. IDOC initially contracted with Wells Center, Inc. to run the program until May 2017 when the WestCare Foundation (Illinois) was awarded the contract. The program funds three full-time employees, including a supervising counselor and two substance abuse treatment counselors.

Eligibility requirements consist of a diagnosis for both a substance use disorder and mental health disorder. Once officially accepted into the program, women are given multiple assessments to learn about their background, medical history, drug and alcohol use, family and school history, relationship history, psychiatric status, and employment history. Tests used include the Buss-Perry Aggression Questionnaire (AQ), the Posttraumatic Stress Disorder Checklist (PCL-5) and the Addiction Severity Index (ASI).

The program consists of three phases:

  1. Pre-treatment orientation phase. Staff get to know clients’ individual needs, planning a course of action to address those needs, familiarizing clients with the program rules and expectations, and engaging the women in treatment.
  2. Main treatment phase. This phase offers treatment services, medication compliance, and leisure activities.
  3. Pre-release phase. This phase includes meetings with a substance abuse treatment counselor, the Illinois Department of Corrections counselor, and the field services representative to help them plan their reentry.

Client Demographics

Twenty-four clients were interviewed, with an average age of 36 years old, 58 percent White and 30 percent Black; half had completed some high school and half had earned at least their diploma/GED; 83 percent had children; and 58 percent reported prior homelessness. Almost all (92 percent) had more than one diagnosed mental health disorder; of those, nearly all reported having anxiety or mood disorders (both 92 percent). Prior traumatic experiences were also common, as seen in Figure 1.

Figure 1

Percentage of clients reporting prior traumatic events (n=24)

Figure 1
Source: ICJIA interviews with program clients
*n= 23 clients

Client and Staff Feedback

Overall, clients thought the program helped them with their disorders. Two, however, reported participating in the program primarily to receive a reduction in their sentence. Clients expressed the importance of cognitive restructuring, problem-solving, and coping skills. Staff interviewed felt the program should be expanded to treat more clients. Currently the program’s capacity is 26. Overall, staff were pleased with the work of the program despite limited resources.

Therapeutic Space

Nearly all clients found the program space to be comfortable and safe. Clients thought the offices for individual counseling were sufficiently private, but one found it depressing because it is not decorated. Staff, however, expressed concerns about the lack of privacy and confidentiality during individual sessions with clients. Staff would prefer separate offices to hold individual sessions. Program staff also mentioned the treatment area does not have air conditioning, which impacts programming because it is uncomfortable and distracting during group and individual counseling sessions.

Privacy Among Clients

Clients reported the biggest issue with the program was fear their private information will be shared with others. One staff confirmed that clients were apprehensive to share in group settings for fear information would be repeated by other clients.

Program and Correctional Staff

Most clients found the counselors welcoming, open-minded, and willing to listen. One staff member stated that the program had “amazing staff,” and highlighted the camaraderie between staff and clients. However, clients thought correctional officers were not respectful or helpful to their recovery. Clients felt correctional officers had the ability to undermine the work that was being done in the program and officers need training on CODs to understand the importance of the Dual Diagnosis program.

Improvement in Posttraumatic Stress Disorder (PTSD)

Twenty-four clients completed a both pre- and post-test that measures PTSD symptoms and severity. Based on DSM-5 diagnostic criteria, before the program 16 women (67 percent) had a probable PTSD diagnosis; after the program, 10 women or 42 percent had a probable PTSD diagnosis. Researchers could not determine, however, whether these improvements were due solely to the program. At the start of the program, the most common PTSD symptom was having strong negative feelings such as fear, horror, anger, guilt or shame (63 percent) followed by blaming themselves or others for stressful experience (58 percent). Figure 2 depicts the severity score distribution using a box-whisker plot, which graphically displays the high and low ends of the distribution of PTSD severity scores (using horizontal brackets). The average PTSD severity score before the program was 41.5 and after the program was 27.8. Based on a validated measure of PTSD, 63 percent responded to treatment and 50 percent had clinically meaningful improvement.

Figure 2

PTSD severity score distribution (n=24)

Figure 2
Source: ICJIA analysis of WestCare Foundation (Illinois) data, client PCL-5 data

Improvement in Client Aggression

Twenty-two clients completed the aggression questionnaire; the average aggression score before the program was 95.4 and the average score after the program was 91.3 (Figure 3). Physical aggression, hostility, and the total score declined, while verbal aggression and anger experienced a slight increase.

Figure 3

Aggression score distribution (n=22)

Figure 3
Source: ICJIA analysis of WestCare Foundation (Illinois) client responses to Buss Perry Aggression Questionnaire

Implications for Policy and Practice

It is recognized that security, limited resources for effective programming, and the prison environment itself can unique challenges to providing evidence-informed and evidence-based programs and practices. Common reasons for limited provision of treatment to prisoners include: budgetary constraints, space limitations, and limited number of counselors.[13] However, based on what was learned from this study, the following are suggestions to improve the Dual Diagnosis program.

Improve the Program’s Physical Space

Therapeutic Space

Interviews with program staff highlighted the need for changes in the physical space that therapies are provided within. Physical environments, including accessories, colors, furniture, lighting, sound, smell, texture, and thermal conditions, have been found to impact the effectiveness of therapy and can even discourage successful treatment of incarcerated individuals.[14] Although prisons often must retrofit their therapy space within existing prison walls, there are things that can be done to modify these spaces.

Housing Unit

Some clients shared with researchers that there was a negative stigma attached to participating in the program. It was suggested that dual diagnosis should have its own house [building/dorm] because it would lessen the stigma from other non-dual diagnosis participants. Specially trained correctional officers could be assigned to the housing unit. This could also lessen the concerns expressed by clients that the correctional officers are not respectful or helpful to the clients. A housing unit could also somewhat address concerns about privacy, so there are less opportunities to share what happens in therapy with other female inmates housed the general population.

Train Correctional Officers

Treatment staff reported a need for correctional officer training in both SUD, MHD, and COD as a means of creating a culture that supports therapeutic efforts while maintaining security. Staff understood that safety in the prison setting was vital, but thought correctional officers could work to improve the overall environment that clients experienced. Further, collaboration and cooperation between treatment staff and correctional staff should be encouraged.

Enhance Program Components

Aftercare

Program staff confirmed the lack of a formalized aftercare portion of the Dual Diagnosis program. This is problematic as aftercare is important in increasing the chances of maintaining improvements that were achieved during treatment. Professionals agree that continuity of care and a high level of support are essential for reentering women with COD.[15] However, additional resources would be needed to include an aftercare component.

Program Make-up Hours

The biggest issue mentioned by the clients was the difficulty in making up missed group hours. They may miss group for a number of non-treatment-related reasons such as illness. These restrictions create a need for more hours and days for make-up groups. Availability of make-up hours is important to meet the program completion requirements and to ensure that participating women benefit from the therapeutic intervention.

Conduct Additional Research

Currently, the program measures PTSD and aggression scores over time to document changes in client symptomology pre- and post-treatment. Program staff should also consider collecting similar scores from those women who are deemed eligible for the program but are currently waiting a program slot. If possible, future research should employ a randomized control trial for client selection, as well as testing new or current aspects of the program. Such a process could shine a light onto what extent the program and program components work for this population.

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