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IIR 14-081 – HSR&D Study

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IIR 14-081
Improving Treatment Engagement and Outcomes among Justice-involved Veterans
Daniel M. Blonigen PhD MA
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: February 2016 - January 2020

BACKGROUND/RATIONALE:
Approximately 146,000 Veterans are released each year from correctional settings; however, two thirds will likely reoffend and return to the justice system. Antisocial cognitions and behaviors are the strongest predictors of reoffending and are highly prevalent among justice-involved Veterans (JIVs). However, in the absence of treatments with demonstrated effectiveness with JIVs, no systematic approach to address antisocial cognitions and behaviors has been implemented in VA. Moral Reconation Therapy (MRT) is a cognitive-behavioral intervention that aims to reduce antisocial cognitions and behaviors. MRT has the best empirical support for reducing risk for criminal recidivism among civilian offenders, and its associated mechanisms (improvements in interpersonal functioning and impulse control) have been linked to improvements in health-related outcomes that are also risk factors for recidivism (substance use, mental health, housing, and employment problems). However, no trials have been conducted with JIVs. Differences between JIVs and justice-involved civilians (e.g., prevalence of traumatic brain injuries; interpersonal problems) suggests prior research on MRT with civilians may not be generalizable, and prompted the VA's Veterans Justice Programs (VJP) and the developers of MRT to develop a Veteran-specific curriculum of this intervention. Testing this new MRT Veteran manual is a top priority of VJP.

OBJECTIVE(S):
Using the new Veteran-specific manual, the overarching objective of the current proposal is to implement and evaluate MRT as an intervention to reduce risk for criminal recidivism and improve health-related outcomes among JIVs in VA Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs). Using a Hybrid Type 1 design, this project will test the effectiveness of MRT in a multisite RCT (Palo Alto, Little Rock, and Bedford) and conduct a formative evaluation to facilitate future implementation of MRT in VA.

METHODS:
In the RCT, 365 Veterans who (a) are entering an MH RRTP, and (b) had been arrested and charged and/or released from incarceration in the past 5 years will be recruited for participation and randomly assigned to one of two conditions: usual care (UC) in the MH RRTP or MRT. In addition to usual MH RRTP activities, patients in the MRT condition will attend group meetings twice per week for 12 weeks. These groups will use a Veteran-specific MRT manual, consisting of assignments to modify participants' antisocial cognitions and behaviors. The Specific Aims of this study are to determine whether adding MRT to usual care in MH RRTPs reduces overall risk for criminal recidivism (Aim 1, Hypothesis 1a); improves health-related outcomes that are risk factors for recidivism (i.e., substance use, mental health, housing, and employment problems) (Aim 1, Hypothesis 1b); and whether the effects of MRT on reduced recidivism risk and better health-related outcomes is mediated in part by greater likelihood of completing the MH RRTP and utilizing SUD/mental health continuing care services (Aim 1; Hypothesis 1c). Patients will be followed at 6 and 12 months post-baseline. We will also conduct a formative evaluation to inform the future implementation of MRT in VA (Aim 2) by identifying (2a) barriers and facilitators to implementation of MRT in MH RRTPs across VA, and (2b) whether and/or how to adapt MRT for diverse subpopulations of Veterans.

FINDINGS/RESULTS:
Data collection is ongoing for the baseline, 6-month and 12-month assessments. At baseline, patients randomly assigned to the control or intervention condition (i.e., MRT) have not differed on any demographic characteristics.

IMPACT:
Criminal recidivism is highly prevalent among Veterans. In the absence of treatments with demonstrated effectiveness with justice-involved Veterans (JIVs), VA has not systematically implemented empirically-supported treatments such as Moral Reconation Therapy (MRT) that aim to reduce antisocial cognitions and behaviors and improve other health-related risk factors for recidivism (substance use, mental health, housing, and employment problems). By testing and implementing MRT in VA residential mental health treatment programs, where most residents have extensive criminal histories, the VA can begin to reduce risk for criminal recidivism among JIVs, and in turn improve the long-term health and well-being of this vulnerable population.

Data collection are on-going and preliminary results cannot yet be obtained until more outcome data from the follow-up assessments are collected. Nonetheless, the operational sponsors of this project (VHA's Veterans Justice Programs; VJP) are expanding access to MRT across the VA and have provided training in MRT to over 100 VJP Specialists and Behavioral Health providers across 70 VA medical centers. Future research of MRT at non-research sites is being planned so as to complement the findings from the present trial.

PUBLICATIONS:

Journal Articles

  1. Blonigen DM, Cucciare MA, Timko C, Smith JS, Harnish A, Kemp L, Rosenthal J, Smelson D. Study protocol: a hybrid effectiveness-implementation trial of Moral Reconation Therapy in the US Veterans Health Administration. BMC health services research. 2018 Mar 7; 18(1):164.
  2. Timko C, Booth BM, Han X, Schultz NR, Blonigen DM, Wong JJ, Cucciare MA. Criminogenic Needs, Substance Use, and Offending among Rural Stimulant Users. Rural mental health. 2017 Apr 1; 41(2):110-122.


DRA: Substance Abuse and Addiction
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Behavioral Therapy, Cognitive Therapy, Substance Use and Abuse
MeSH Terms: none