Abstract
Drug Court Treatment (DCT) Programs seek to integrate substance abuse treatment into the criminal justice system by providing a structured environment for offenders who engage in treatment in lieu of incarceration. DCT has shown successes in reducing drug/alcohol use, recidivism, and cost, but the impact of DCT on non-substance-related mental health outcomes is less clear. This study evaluated mental health correlates within a DCT sample through analyses of participants’ pre-entry and pre-graduation Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2) profiles. When diagnostic information was available, mood disorders had the highest comorbidity with alcohol/substance use diagnoses. Comparisons across administrations of the MMPI-2 indicated significant differences among mean scores on 6 Clinical scales, and mean profile elevation scores significantly decreased. Results suggest a significant presence of mental health comorbidities in DCT programs, and significant mental health improvements were seen for graduates, suggesting the utility of DCT for treating mental health problems in addition to substance use.
As specialty courts, such as Drug Court Treatment (DCT) programs, become more popular, it is important to examine the myriad of ways these services can positively impact society. Beyond the well-known effects of mitigating substance use and saving taxpayer dollars through reduced substance-related recidivism (Marlowe, 2010), DCTs can have a positive impact on participants’ mental health. The current study is among the first to examine the relationship between DCT program participation and improvement in mental health functioning.
Since the early 1980s, changing U.S. drug policies have contributed to the rapidly increasing incarceration rates for substance-related offenses (Belenko et al., 2007). Between 1970 and 2004, harsher criminal sanctions aimed at promoting the “war on drugs” resulted in a 400% increase in incarceration admissions, with substance users contributing to an approximately 60% increase in federal inmate populations and a 30% increase in state inmate populations (DeMatteo et al., 2011; Harrison & Beck, 2005). As governing and legal groups continue to seek methods to reduce maintenance costs for jails and prisons, interest is growing in programs aimed at deferred adjudication of repeat substance use offenders to treatment and community programs (Peters et al., 2012, 2015). However, a significant obstacle in the deferred adjudication model is the effective management of individuals who have comorbid mental and substance use disorders (CODs).
A major contribution to the national trend of prison, jail, and probation growth can be attributed to arrest rates and increased recidivism for drug-involved offenders (Peters et al., 2012, 2015). Substance users are often repeatedly cycled through the legal and correctional system as a result of untreated substance use disorders and consequent drug-related crime charges. Those who experience chronic distressing psychiatric symptoms may utilize illicit substances as a maladaptive coping strategy aimed at mitigating unwanted symptoms (Peters et al., 2015). Mental health disorders are common among those with substance use disorders, those engaged in substance abuse treatment programs, and especially in populations of offenders diagnosed with co-occurring substance use disorders (Peters et al., 2012, 2015); Mental illness rates are 3 to 4 times higher in prison and 4 to 6 times more likely in jail than in the general population (Peters et al., 2012, 2015). Notably, 34% of female offenders and 17% of male offenders have demonstrated symptoms congruent with a non-substance-related psychiatric diagnosis, including a major depressive disorder, a bipolar disorder, a schizophrenia spectrum disorder, or post-traumatic stress disorder (PTSD; Steadman et al., 2013). In addition, 70% to 74% of those with non-substance-related diagnoses have also been diagnosed with a co-occurring substance use disorder (Steadman et al., 2009, 2013).
It is evident that CODs serve as a potential moderating factor in understanding the recidivism rates of substance users within the legal system. Individuals with CODs are not only more likely to have frequent legal difficulties but also more likely to experience homelessness, financial difficulties, lack of social support, and lower vocational and educational levels (Peters et al., 2012, 2015). Serious mental illnesses, particularly when paired with comorbid substance use, have been linked to increased violence within communities (Elbogen & Johnson, 2009; Hodgins et al., 2008; Peters et al., 2015; Van Dorn et al., 2012). Of note, substance use appears to impact chronicity of individual crime occurrence. Jail inmates with mental health diagnoses are more likely to report drug use in the month preceding their arrest than those without diagnoses (Peters et al., 2012, 2015). It appears that drug-involved offenders are major contributors to the national trend of prison, jail, and probation growth as a result of not only arrest rates but also increased recidivism. Substance users are often repeatedly cycled through the legal and correctional system as a result of untreated substance use disorders and consequent drug-related crime charges.
Mental health diagnoses and substance use disorder symptoms are often left untreated while individuals are incarcerated or on probation, despite their significant impact on crime and recidivism rates (Marks & Turner, 2014; Rice et al., 1991). In a meta-analysis comparing the effects of court-ordered programs for drug-using offenders, traditional programming such as drug testing in pretrial release, intensive supervision, and community surveillance exhibited no effect in reducing recidivism and substance use, in comparison to long-term substance use treatment (Perry et al., 2009). Lack of focus on psychiatric history within forensic settings results in frequent under-diagnosis of CODs, and those with CODs have demonstrated significantly higher recidivism rates than drug offenders without CODs (Peters et al., 2015). Controlled studies of the efficacy of justice-involved COD programs demonstrate that reincarceration rates, violations, and probation revocations are significantly lowered when specialized supervision teams and treatment protocols are provided to participants, as compared to customary prison mental health services (Peters et al., 2015; Sacks et al., 2012). As such, typical court-recommended programs for substance using offenders may consequently be inappropriately matched to individual mental health needs and may not address presenting problems adequately (Peters et al., 2012, 2015). DCT programs may serve as a particular type of court-ordered program that is uniquely suited to treat both substance use disorders and mental health difficulties.
DCT Model
Given the high rates of substance use among offenders, the need for effective treatment programs has amplified. However, traditional substance use treatment programs have not seen large successes in reducing recidivism for drug-using offenders, typically due to failure to initiate substance use treatment and high drop-out rates (Belenko et al., 2007; Marlowe, 2002; Marlowe et al., 2016). DCT programs have been developed in response to offender need, to increase the likelihood of individuals to engage in treatment, and to improve outcomes for substance users charged with drug-related crimes. These programs are especially suited for substance abusing offenders, as they provide the opportunity for efficient management and early intervention in the community (Peters et al., 2012).
The DCT model has seen numerous successes in terms of reduced criminal recidivism, substance use, and cost to the community (Aos et al., 2006; M. Green & Rempel, 2012; Latimer et al., 2006; Lowenkamp et al., 2005; Marlowe, 2010; Shaffer, 2006; Wilson et al., 2006; Wittouck et al., 2013). DCT programs have exhibited reductions in recidivism ranging from 8% to 26%, with these reductions lasting up to 3 years post entry (Marlowe, 2010). In addition to reduced recidivism, participants reported reductions in illicit drug and alcohol use, which has been confirmed by drug testing (Marlowe, 2010). Significant reductions in costs to communities have also been cited, with an average benefit of US$3,000 to US$13,000 per participant to the community, compared to traditional criminal justice involvement. In addition to reductions in recidivism, substance use, and cost, several qualitative improvements have also been associated with participation in DCT programs (Marlowe, 2010). Decreased familial conflict along with increased support, and improved socioeconomic well-being as measured by increased likelihood of employment and/or enrollment in an education program, are factors impacted by DCT involvement (M. Green & Rempel, 2012). Furthermore, in a qualitative study examining DCT participants’ attitudes toward the program, additional gains were cited, including skills for success such as time management, increased willingness to change, better decision-making, and improved self-control, among other expected goals based on the treatment model (Liang et al., 2016). Results suggest that though not part of the originally intended aims of the DCT model, DCT programs may have the unique opportunity to incorporate a holistic approach and improve the general well-being for DCT participants.
Mental Health Needs of DCT participants
A significant challenge facing DCT programs is addressing mental health needs of participants beyond substance use (Steadman et al., 2013). Although not the primary aim of DCT programs, an increasing number of individuals present to treatment with CODs (Peters et al., 2012; Weitzel et al., 2007). Surveys of DCT participants (Ns = 108–1,156) reveal significant levels of mental health concerns, with up to 63% of participants endorsing at least one mental health concern (Cissner et al., 2013; M. Green & Rempel, 2012; Peters et al., 2012; Weitzel et al., 2007). Prevalence of mental health concerns varied across surveys of participants, but the most common mental health concerns identified by participants were major depression (16%–39%), PTSD (10%), anxiety disorders (9%), and bipolar disorder (8%). Notably, a substantial number of participants endorsed a history of abuse or trauma (27%–29%). However, little is known about mental health outcomes of those who participate in DCT programs.
Previous investigations suggest improvements in general mental health outcomes for DCT participants (M. Green & Rempel, 2012); however, these non-specific improvements do not provide substantial insight into the nature of these improvements, resulting in a paucity of data for treatment tailoring and recommendations. Several specific features of DCT programs may be uniquely suited to promote reduction in symptoms of CODs. First, within mandated treatment programs, abstaining or strictly limiting substance use initiates some aspects of mental health recovery (C. A. Green et al., 2015; Wilson et al., 2006). Second, meta-analyses of substance use programs demonstrate that peer support has a beneficial effect on participant sobriety (Bassuk et al., 2016). Furthermore, in studies of trauma-informed substance abuse recovery, social bonds and peer support are linked to lessened trauma symptomology (Jain et al., 2012; VandeMark et al., 2004). Third, graduated sanctions and rewards are built into the DCT model to aid in behavioral modification. The judge serves as a primary figure within the team framework who is responsible for accountability and engagement of participants, allowing mental health providers to solely attend to therapeutic issues. Sanctions and rewards, especially those provided by a judge, have been shown to serve as motivators of participant program completion and therefore enhanced potential for long-term sobriety and general mental health benefits (Marlowe et al., 2006; Wilson et al., 2006). Fourth, careful assessment at program entry and monitoring of patient symptoms through program participation allows for specific treatment tailoring. Knowledge of the presence of CODs at participant entry may allow DCT providers to offer interventions and services aimed at improving clients’ mental health in conjunction with substance use reduction. Therefore, if a client’s mental illness serves as a potential roadblock in the treatment and recovery process, more direct intervention on COD symptoms may increase the likelihood of successful program completion, as well as reduce post-program recidivism and relapse (Wilson et al., 2006).
The Present Study
The aims of the current study were twofold: (a) to examine the nature of mental health needs within a DCT population by investigating the proportion of DCT participants who meet diagnostic criteria for a COD and (b) to evaluate differences in mental health functioning pre- and post-participation in the program. It is expected that significant differences in personality profiles as measured by the Minnesota Multiphasic Personality Inventory—Second Edition (MMPI-2) would be yielded for graduates of the program, as is consistent with differences that have been observed for individuals engaged in long-term substance abuse treatment (Polimeni et al., 2010). Specifically, we expected to find significant differences on the Clinical scales assessing Depression (D), Psychopathic Deviate (Pd), Paranoia (Pa), Psychasthenia (Pt), and Schizophrenia (Sc), as consistent with findings yielded by Polimeni and colleagues (2010).
Method
Participants
The sample consisted of 106 participants engaged in the local county DWI/Drug Court program in McLennan County, Texas between October 2010 and January 2019. The sample was predominantly male (N = 70), with a mean age of 38.34 (SD = 11.17). Participants self-identified as Caucasian (65.1%), African American (16%), Native American (0.9%), Mixed (0.9%), Asian (0.9%), and Other (0.9%), and 15.1% identified as Hispanic/Latino. A majority of individuals identified their substance of choice as alcohol (62.7%), followed by cannabis (25.5%), stimulants (5.9%), opioids (3.9%), sedatives (1%), and hallucinogens (1%).
The local DCT, which has been in existence since 2007, is a post-adjudication program that targets first and second time DWI offenders, and those who have alcohol or drug-related offenses who fail to comply with probation mandates to remain alcohol and drug free. Although rare, the program has accepted participants (<5) with records of violent offenses; however, those offenses were limited to family violence incidents committed in the context of alcohol or drug use. Program requirements are presented in Table 1 and include intensive outpatient treatment for substance use disorders, aftercare consisting of group psychotherapy targeting substance use, and Alcoholics/Narcotics Anonymous participation, abstinence from all drugs and alcohol, weekly drug screening and interaction with the probation officer, stable full-time employment, and regular court attendance. Individuals also participate in individual therapy aimed at reducing substance use, and they may also participate in additional individual therapy for CODs tailored to treatment needs. Program engagement lasts a minimum of 12 months. Prior to movement into the last phase of the program, which takes place approximately 3 months prior to completion of the program, participants are administered a second evaluation to evaluate risk for relapse and treatment gains.
Program Requirements of the McLennan County DWI/Drug Court Program.
Note. Listed above are the average requirements for the DCT program. In addition, participants are required to participate in individual therapy aimed at substance abuse treatment, which varies in frequency based on client needs. Furthermore, individuals may also participate in individual therapy for comorbid mental and substance use disorders (CODs), tailored to their specific needs. DCT = Drug Court Treatment.
Measures
Minnesota Multiphasic Personality Inventory -- Second Edition
The Minnesota Multiphasic Personality Inventory -- Second Edition (MMPI-2) (Butcher et al., 1989) is a 567-item self-report measure of personality functioning and symptomatic patterns. The items comprise 14 scales: four Validity scales and 10 Clinical scales. Only the clinical scales were analyzed for the purposes of this study. The Clinical scales assess dimensions of personality, psychopathology, and problematic functioning, which can be used to aid in diagnosis. The Clinical scales assess constructs related to Hypochondriasis (Hs; concern with bodily function, illness, and disease), Depression (D; dissatisfaction or absence of happiness, low self-worth, lack of interest, social withdrawal, and physical complaints), Hysteria (Hy; specific somatic complaints and a defense of denial of psychological, emotional, or interpersonal problems), Psychopathic Deviate (Pd; antisocial behavior, lack of conformity to social norms, impulse control problems, and interpersonal exploitation), Masculinity-Femininity (Mf; the extent to which an individual identifies with stereotypical masculine or feminine interests including occupational identification, altruism, sexual identification, and personal/emotional stability), Paranoia (Pa; a range of paranoid experiences from interpersonal hypersensitivity, suspiciousness, and moral self-righteousness, to delusions of persecution and ideas of reference), Psychasthenia (Pt; presence of anxiety, difficulty with concentration, self-doubt, and obsessional cognition), Schizophrenia (Sc; bizarre thought processes, peculiar perceptions, poor family relationships, social alienation, apathy, and a tendency to withdraw into fantasy), Hypomania (Ma; manic and hypomanic symptoms such as increased motor activity, energy level, expansiveness, elevated mood, irritability, and grandiosity), and Social Introversion (Si; shyness, social ineptness, social withdrawal, and discomfort with others and oversensitivity to others’ perceptions). The instrument is standardized for use with individuals over the age of 18 years, and it is worded at a Grade 6 reading level. Scores are obtained from respondent’s rating of true or false items. The instrument has been used extensively with legally involved and substance using populations (e.g., Butcher et al., 2015; Otto, 2002).
The MINI International Neuropsychological Interview
The MINI International Neuropsychological Interview (MINI) is a brief structured interview aimed at assessing for a majority of the Axis I psychiatric disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000; Sheehan et al., 1998). The measure consists of 16 separate modules, which assess for symptoms of the following DSM-IV-TR diagnoses: Agoraphobia, Alcohol Dependence/Abuse, Anorexia Nervosa, Bulimia Nervosa, Generalized Anxiety Disorder, Manic Episode/Bipolar Disorder, Obsessive Compulsive Disorder, Panic Disorder, Posttraumatic Stress Disorder, Psychotic Disorders, Social Phobia (Social Anxiety Disorder), Substance Dependence/Abuse, and Suicidality. The instrument is intended for use with individuals aged 18 years and older, and individuals confirm or deny the presence of symptoms associated with the aforementioned diagnoses. The instrument has been validated for use with for screening and assessment of CODs in the justice system (Substance Abuse and Mental Health Services Administration, 2015).
Procedure
Participants’ MMPI-2 profiles were obtained through pre-sentencing evaluations conducted for the DCT to determine program eligibility. Evaluations were conducted by trained doctoral-level clinical psychology students, supervised by a licensed clinical psychologist. Pre-sentencing evaluations screen for psychopathology, trauma-related symptoms, severity of substance use, and cognitive abilities to determine whether the DCT program appropriateness and to provide treatment recommendations. Participants were administered a second evaluation prior to movement to the final phase of the program to evaluate risk for relapse and any remaining treatment needs. Informed consent for participation in the clinical evaluations was obtained from participants prior to the start of both pre-sentencing and pre-graduation evaluations. Data from evaluations were retrospectively obtained upon participants’ graduation from the program, as approved by the local Institutional Review Board.
Pre-sentencing evaluations of all participants admitted to the program between October 2010 and January 2019 were examined to gain information regarding mental health concerns of participants who engaged in the DCT program (N = 106). Invalid profiles were excluded from the sample based on all of the following criteria: scores greater than 80T on the Variable Response Inconsistency (VRIN) scale, greater than 80T on the True Response Inconsistency (TRIN) scale, scores greater than 100T on the Infrequency (F) scale, scores greater than 80T on the Lie (L) scale, scores above 75T on the Correction (K) scale, and scores above 75T on the Superlative Self-Preservation (S) scale, as suggested by guidelines suggested by one of the authors of the instrument (Graham, 2012) and guidelines for use with offender populations (Forbey & Ben-Porath, 2002). Personality profiles of 19 participants were excluded from the analyses due to validity concerns. Descriptive analyses determined mean MMPI-2 scores for the sample (N = 87), as well as frequency analyses for diagnostic information from the MINI. It should be noted that diagnostic information was only available for a portion of the sample (N = 39), as the MINI was added to the assessment protocol midway through the data collection time period.
To examine the relationship between mental health functioning and engagement in the DCT program for graduates of the program (N = 62), data were obtained from both valid pre-sentencing and valid pre-graduation evaluations from program graduates (N = 35). In all, 62 participants graduated from the program between October 2010 and January 2019. In addition to the 19 participants excluded due to validity concerns on pre-sentencing profiles, eight additional profiles were deleted due to validity concerns for the pre-graduation profiles, resulting in a sample of 35 participants for these analyses. Paired Samples t-tests were used to examine differences on MMPI-2 scores across administrations. Cohen’s d statistic was also calculated for each comparison to determine the magnitude of the difference between scores. Comparisons were only made for eight of the 10 Clinical scales, excluding the Masculinity-Femininity (Mf) and Social Introversion (Si) scales. An a priori power analysis conducted using G*Power 3.1 (Faul et al., 2007) indicated that the sample size was adequately powered (
Additional analyses of profile characteristics were also utilized as outlined in two studies comparing MMPI profiles across multiple administrations (Chojnacki & Walsh, 1992; Munley, 2002). Pearson product-moment correlations were calculated for each scale to determine the relationship between scores across administrations. Each profile was examined to calculate the total number of clinically elevated scales, which included any scale with a T-score greater than 65, to determine the consistency in number of elevated scales across administrations. Furthermore, the average number of T-score points that a profile was elevated on each scale was also calculated and compared across administrations.
The Modified D statistic (Chojnacki & Walsh, 1992; Osgood & Suci, 1952) was also calculated to investigate variance in profiles across the two administrations. The Modified D statistic was chosen to analyze profile variance due to its utilization in previous studies comparing MMPI-2 profile variance across multiple time points (Chojnacki & Walsh, 1992; Munley, 2002) and relative ease of interpretation of analyses. The Modified D statistic was calculated by summing the absolute differences across administrations for each scale, which represents the number of T-score points that the profile varies across administrations.
Results
Descriptive Statistics
Descriptive statistics were analyzed for all individuals admitted to the DCT program with valid MMPI-2 profiles (N = 87), as 19 profiles from the original analyses were excluded due to validity concerns. The majority of the sample was male (67.8%), with an average age of 38.54 (SD = 11.44) years. The sample predominately self-identified as Caucasian (64.4%), followed by African American (16%), Native American (1.1%), Mixed (1.1%), Asian (1.1%), Other (1.1%), and 14.9% identified as Hispanic/Latino. A majority of participants indicated that alcohol was their substance of choice (60.9%), followed by cannabis (24.1%), stimulants (5.7%), opioids (4.6%), and hallucinogens (1.1%).
The mean T-score across Clinical scales was 57.75 (SD = 9.21) for all participants. Notably, the highest mean score across all Clinical scales of the MMPI-2 was the Psychopathic Deviate scale (M = 64.25, SD = 12.95). Interestingly, none of the means of the MMPI-2 met the level of clinical significance (T = 65); however, the Psychopathic Deviate (Pd) scale was close to clinically elevated. When diagnostic information was available (N = 39), 80.0% of participants entering the program met diagnostic criteria for an Alcohol Use Disorder and 67.9% met diagnostic criteria for a Substance Use Disorder, as measured by the MINI Neuropsychiatric Diagnostic Interview. The most common CODs were Major Depressive Disorder (51.9%), Panic Disorder (9.1%), PTSD (9.1%), and Generalized Anxiety Disorder (9.1%), suggesting a significant prevalence of mental health needs among this population.
Relationship Between MMPI-2 Administrations
Figure 1 presents the means of the profiles across administrations. In evaluating the differences between pre-sentencing and pre-graduation MMPI-2 profiles for graduates (N = 35) of the DCT program, correlation coefficients for T-scores averaged .43 (ps = .001–.196), which suggests variance in profile shape from pre-sentencing to graduation. All correlations were significant with the exception of the Paranoia (Pa) scale. The scores on the Hypomania (Ma) scale shared the highest association across administrations (r = .53, p = .001). Paired samples t-tests revealed significant differences for six out of the eight Clinical scales, with the exception of the Hypochondriasis (Hs) and Hysteria (Hy) scales. To adjust for inflated Type I error due to the number of statistical analyses conducted, adjusted alpha levels were conducted based on the False Discovery Rate (Benjamini et al., 2001) method. Results of the paired-samples t-tests remained significant after adjusting for multiple comparisons. Means, standard deviations, correlations, results of the paired-samples t-tests, adjusted alpha values, and Cohen’s d for each scale across administration are presented in Table 2. The magnitude of these differences ranged from small to medium in size (average d = .57) with the Psychasthenia (Pt) scale exhibiting the largest decrease across administrations (d = .70).
Graphical representation of MMPI-2 profiles for graduates of the DCT program.
MMPI-2 Profile Characteristics for Pre-Sentencing and Pre-Graduation Profiles.
Note. Table 2 shows mean difference calculations for pre-sentencing and pre-graduation MMPI-2 profiles for graduates of the DCT program. Depression, Psychopathic Deviate, Paranoia, Psychasthenia, Schizophrenia, and Hypomania scales exhibited significant differences across administrations. MMPI-2 = Minnesota Multiphasic Personality Inventory—Second Edition; DCT = Drug Court Treatment.
*p < .05.
**p < .01.
Profile Elevation Statistics
Across administrations, mean profile elevations significantly decreased from 18.49 T-score points (SD = 28.46) to 5.34 T-score points (SD = 16.12; d = 0.57). It should be noted that although a majority of profiles yielded significant decreases across administrations, 11.4% of profiles exhibited elevations on scales on the pre-graduation MMPI-2 profile that were not elevated in the pre-sentencing evaluation. The most common scale elevated was Psychasthenia (Pt). The average of the modified D statistic indicates that the individual profiles changed an average of 74 T-score points across administrations (SD = 41.02). Overall, profile elevation analyses suggest a significant decrease in elevation across the Clinical scales.
Discussion
The link between substance use disorders and various mental health diagnoses is well established in forensic and psychological literature (Steadman et al., 2009, 2013). DCT programs across the country have demonstrated effectiveness in reducing rates of recidivism and relapse in chronic offenders of substance-related crimes (e.g., Aos et al., 2006; Marlowe, 2010). As such, understanding how DCT programs, which do not necessarily target mental health symptoms, indirectly impact those symptoms, can increase these programs’ effectiveness even more. The present study sought to explore mental health comorbidities within a DCT program, as well as to investigate changes in self-reported mental health symptoms associated with program engagement.
Overall, results supported previous investigations of rates of CODs within a DCT program population (Cissner et al., 2013; M. Green & Rempel, 2012; Peters et al., 2012; Weitzel et al., 2007). The most common CODs among the sample were Major Depressive Disorder, PTSD, Panic Disorder, and Generalized Anxiety Disorder. In addition, it should be noted that several participants in the program did meet diagnostic criteria for Bipolar Disorder (approximately 4%) as measured by the MINI; however, when MMPI-2 profiles were excluded based on validity concerns, these cases were deleted. Results suggest a need for treatment of CODs, which may be accomplished through engagement in a DCT program. The evaluation of mental health functioning at pre-entry to the DCT program compared to prior to program graduation suggests that improvement in functioning is related to program participation.
Significant differences were found across administrations for six out of the eight examined Clinical scales on the MMPI-2, with the magnitude of the differences ranging from small to large in size. The largest difference was on the Psychasthenia (Pt) scale, which suggests that participants’ levels of anxiety decreased significantly throughout the program. These results are not surprising, as overall level of stress and anxiety tend to lessen as individuals adapt to the demands of the DCT program, make life changes (e.g., stable employment, abstinence, financial stability), and anxiety surrounding legal status (e.g., anxiety related to potential incarceration, worries about failing drug tests) lessens. It should be noted that a small number of profiles exhibited an increase of scores on the Psychasthenia (Pt) scale, which may be consistent with anxiety related to completion of the program and leaving structured treatment. Other significant decreases include decreases on the Depression (D), Paranoia (Pa), and Schizophrenia (Sc). These decreases are consistent with improvement expected by long-term substance use treatment and treatment for CODs, such as depression and characteristic of program participation (Drake et al., 1998; Polimeni et al., 2010). In addition, scores on the Hypomania (Ma) scale also significantly decreased, which is notable due to the exclusion of profiles of those with a Bipolar Disorder diagnosis due to validity concerns. This significant decrease may be explained by a decrease in levels of irritability, rather than other manic symptomatology. Finally, a significant decrease on the Psychopathic Deviate (Pd) scale suggests that changes in antisocial behavior and thinking are related to program participation which holds promise for decreased recidivism.
Although a number of specialty court services, such as Veterans’ Court or Mental Health Court programs, are typically available to individuals involved in the legal system, potential participants are often rejected from non-DCT courts following admissions of ongoing illegal drug use (Luskin & Ray, 2015; Wolff et al., 2011). Empirical work investigating the selection process for specialty court services is scarce, but existing findings suggest that participants who acknowledge ongoing substance use are rejected due to biases in the selection process and lack of specialized treatment resources within non-DCT programs (Luskin, 2001; Luskin & Ray, 2015). Although alternative specialty court services were not available to the population involved in the present study, future research may benefit from comparing treatment efficacy across various modalities of legal diversion programs.
The population utilized for the present analysis consists of individuals who were referred to the DCT program upon recognition by legal, judicial, forensic, and mental health professionals, as well as the participants’ themselves, that their repeated offenses are due to underlying struggles with substance use. Accordingly, a number of DCT-specific features are likely to have facilitated the mental health symptom reduction experienced in this sample. Empirically supported features of successful DCT programs such as abstaining from substance use (C. A. Green et al., 2015), graduated sanctions and rewards (Marlowe et al., 2006), and detailed psychological assessments (Rossman & Zweig, 2012), were all utilized throughout the program to promote mental health recovery. Peer support has also been shown to promote participant sobriety and facilitate a reduction of trauma symptomology (Bassuk et al., 2016). Participants in the present DCT program receive frequent peer support in the form of shared treatment experiences and court dates. Furthermore, previous research has demonstrated the importance of the multidisciplinary psychological and legal team approach utilized in the present DCT program (Drake et al., 1998; Rossman & Zweig, 2012). For example, in two studies of co-occurring mental health and substance use disorders, integrated outpatient treatment teams demonstrated greater efficacy than traditional individual services or controlled inpatient settings (Drake et al., 1998; Rossman & Zweig, 2012). Finally, due to the significant overlap between substance use and mental health in this population where for many individuals may use substances to cope with symptoms of psychopathology, it follows that substance use treatment may also indirectly address mental health concerns, consistent with the results from studies comparing MMPI-2 profiles of individuals engaged in long-term substance use treatment (Polimeni et al., 2010).
The present study had numerous strengths in its design, method, and implementation. Participants included in analyses were of diverse ethnoracial, sociodemographic, diagnosis type, and treatment backgrounds, allowing for greater generalizability and a more representative sample. Methodological limitations include the small sample size of graduates (N = 35) for the comparison of mental health functioning over the course of program participation. Due to validity concerns, a number of profiles were deleted across administrations which resulted in a small sample of graduates. Although the sample size is adequate to perform the conducted analyses, this sample size may not have been large enough to detect small effect sizes. This may explain why the Hypochondriasis (Hs) and Hysteria (Hy) scales on the MMPI-2 did not reach statistical significance. In addition, the small sample size raises limitations regarding the stability and generalizability of results. This sample represents one DCT program from one county from one state; thus, generalizability of results may be limited to other DCT programs. Future studies should employ larger sample sizes, as well as samples from a number of DCT programs in different geographic regions, to test replicability and generalizability of study results. Moreover, the number of analyses utilized to examine differences between pre- and post-test means raises concerns about the inflated risk of Type I statistical errors. Although statistical error was controlled for in analyses by adjusting alpha using the False Discovery Rate (Benjamini et al., 2001), due to the exploratory nature of these analyses, results should be interpreted with caution and future studies should aim to replicate study results. Furthermore, although the MMPI-2 is able to generally measure symptomatology, the scales alone are not able to provide diagnostic information. Future studies may consider utilizing a more face-valid measure such as the Personality Assessment Inventory (PAI; Morey & Staff, 1991), which may offer a better estimation of Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) diagnostic criteria. Finally, there was no control group of those who were not admitted into the program to compare mental health implications. The use of a control group would aid in determining whether these differences can be fully attributed to participation in the DCT program, or it may be the result of time passed.
In addition, further concerns regarding generalizability are raised due to the variability of participant experience in the DCT program. While some participants receive individual psychotherapy or pharmacological treatment during their time in the program, others only engaged with standard mental health and relapse prevention services (e.g., individual and group treatment aimed at reducing substance use). In addition to standard services included in the DCT model, individual Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), and Seeking Safety informed treatments were available for participants. Treatment plans were individually tailored to participant needs following clinical assessment, with some participants voluntarily seeking therapy services and others receiving treatment mandates based on clinical team recommendations. Quantification of additional services received, attention to mandated versus voluntary help-seeking behavior, medication prescription and adherence, and symptom reduction within individual treatment were not available for analysis. Participant attitudes toward sobriety and the program were also not available in a quantifiable format. Attitudes may be a crucial moderator in DCT efficacy, as is suggested by literature detailing coercion’s negative effect on substance abuse treatment outcomes (Farabee et al., 1998).
The current findings suggest that DCT programs are not only successful in reducing recidivism, costs, and substance use but may also be related to reductions in psychiatric symptomatology. DCT programs were initially developed to mitigate the rising and untenable prison population in response to the well-demonstrated link between substance use and criminal charges. However, in light of the potential mental health treatment efficacy of these programs, new opportunities become salient. DCT programs have the unique potential to address not only substance-related life stressors but also mental health symptoms. The evidence presented here may encourage further psychological and forensic research and eventual policy change. For those participants experiencing co-occurring substance and psychological disorders, outcomes aimed at rehabilitation and recovery appear more productive and less costly than typical consequences, which include probation and prison or jail time. Despite the aforementioned methodological limitations of the present study, as one of the first studies to examine the relationship between mental health functioning and DCT participation, study results contribute to the literature and provide groundwork for future research.
Future studies may address the limitations of the present study by further quantifying variations in individual mental health treatment and pharmacological interventions. In addition, as much past research has investigated the efficacy of various modalities of treatment on patient outcome (i.e., Cognitive Behavioral Therapy, Motivational Interviewing, Psychodynamic), it may prove fruitful to confirm that such findings apply within the mandated DCT model. As previously reviewed, participant attitudes toward sobriety and treatment, particularly within a coercive structure, may be a crucial factor in participant success. Given the current rise in benzodiazepine and opioid use in the United States, and therefore the likely rise of the percentage of users within DCT programs, special attention to these classes of drug may be necessary and useful.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
