The purpose of this study was to examine the history of arrests among dually diagnosed patients entering treatment, compare groups with different histories on use of treatment and mutual-help groups and functioning, at intake to treatment and six-month, one-year, and two-year follow-ups, and examine correlates and predictors of legal functioning at the study endpoint. At treatment intake, 9.2% of patients had no arrest history, 56.3% had been arrested for nonviolent offenses only, and 34.5% had been arrested for violent offenses. At baseline, the violent group had used the most outpatient psychiatric treatment and reported poorer functioning (psychiatric, alcohol, drug, employment, and family/social). Both arrest groups had used more inpatient/residential treatment and had more mutual-help group participation than the no-arrest group. The arrest groups had higher likelihood of substance use disorder treatment or mutual-help group participation at follow-ups. Generally, all groups were comparable on functioning at follow-ups (with baseline functioning controlled). With baseline arrest status controlled, earlier predictors of more severe legal problems at the two-year follow-up were more severe psychological, family/social, and drug problems. Findings suggest that dually diagnosed patients with a history of arrests for violent offenses may achieve comparable treatment outcomes to those of patients with milder criminal histories.
An increased risk for violent crime has been identified among individuals with dual substance use and mental health disorders, compared with general populations or persons with only mental health diagnoses [
In a large sample of offenders released from prison and referred to substance use disorder (SUD) treatment programs, 61% were dually diagnosed, and 27% had at least one violent offense during the six-month period preceding the arrest that led to their incarceration. Comparisons of participants with and without violent offenses found that the violent group had more psychiatric hospitalizations (lifetime), but there was no difference on previous SUD treatments [
A study of SUD patients identified predictors of greater participation in continuing care and mutual-help groups during the three months following completion of an intensive outpatient SUD program. More severe legal problems at the time of completion of the intensive program predicted more mutual-help group participation (but not more treatment utilization) at the level of a trend [
Dually diagnosed Veterans’ rates of having been charged with a crime were 11% in the year prior to receiving VA behavioral health services and 7% in the year after receiving services (a statistically significant decrease [
At baseline, we collected data from 304 dually diagnosed patients. The sample was enrolled using the following procedure: patients entering outpatient mental health treatment and identified by program staff as having dual substance use and psychiatric disorders (based on the program’s standard assessment procedures and medical record review) and as cognitively competent to provide informed consent were invited to participate in the study. Data were collected as part of an ongoing evaluation of treatment for dually diagnosed patients. Outpatient treatment was oriented toward the delivery of evidence-based practices (e.g., cognitive-behavioral, mindfulness approaches) in multidisciplinary individual and group therapy sessions that emphasized teaching skills such as symptom or stress management and relapse prevention. Out of 343 consecutive patients approached about the study, 39 refused to participate. Stanford University’s Institutional Review Board for Human Subjects in Medical Research approved all study procedures, and all participants signed an informed consent form. According to the medical record, psychiatric diagnoses were mainly a major depressive or another mood disorder (60.5%) and PTSD (34.9%), and most participants had both alcohol and drug use disorders (65.5%).
Follow-up rates were 81% (
To assess
We also used the ASI to assess
To assess
Mutual-help group participation was assessed at follow-up as it was at baseline, that is, any attendance, number of meetings attended, number of steps worked, and extent of involvement. The 6-month and 1-year interviews asked about participation over the past 6 months; the 2-year interview asked about participation over the past year.
At follow-ups, the ASI was used to assess functioning (i.e., participants’ legal, alcohol, drug, psychological, employment, family/social, and medical composite scores). Symptoms in the past 30 days were assessed with regard to trouble controlling violent behavior, serious depression, serious anxiety, and trouble understanding, concentrating, or remembering (0 = no, 1 = yes).
At baseline, we compared three groups: lifetime history of (1) no arrests, (2) one or more of nonviolent offense arrests only, and (3) one or more of violent offense arrests. We used analyses of variance (ANOVAs) for continuous outcome variables and chi-square tests for categorical outcome variables. At follow-ups, we compared the three groups’ treatment and mutual-help group participation using ANOVAs and their functioning using analyses of covariance that controlled for the baseline value of the outcome under consideration. To examine correlates of legal functioning at the 2-year follow-up, we conducted multiple regressions in which groups’ arrest status was controlled (0 = none, 1 = nonviolent, 2 = violent) in examining concurrent associations of ASI alcohol, drug, psychological, employment, family/social, and medical composite scores with the ASI legal composite score. We then conducted lagged regressions to examine associations of ASI composite scores at the 6-month and 1-year follow-ups with ASI legal functioning at 2 years, controlling for group status at baseline.
At intake to treatment, only 9.2% (
Comparisons at baseline of the three groups of patients—those with no arrest history or a history of nonviolent or violent arrests—are in Table
Baseline characteristics of dually diagnosed patients with no arrests (
Nonviolent | Violent arrests |
|
||
---|---|---|---|---|
No arrests | Arrests | |||
Demographics | ||||
Male (%, |
92.9 (26) | 91.8 (157) | 90.5 (95) | 0.23 |
White (%, |
53.6 (15) | 50.3 (86) | 45.7 (48) | 0.80 |
Age (M, SD) | 51.0 (9.5) | 50.9 (9.6) | 51.4 (7.3) | 0.12 |
Years of education (M, SD) | 13.9 (2.7) | 13.5 (1.8) | 13.4 (2.0) | 0.52 |
Employed (%, |
35.7 (10) | 46.7 (79) | 45.2 (47) | 1.20 |
Married (%, |
21.4 (6) | 12.4 (21) | 6.7 (7) | 5.02 |
Treatment history: number of episodes (M, SD) | ||||
Outpatient | ||||
Alcohol | 1.1 (1.9) | 2.2 (2.5) | 2.0 (2.5) | 2.32 |
Drugs | 0.8 (1.7) |
2.1 (2.4) |
1.8 (2.3) | 3.70 |
Psychiatric | 2.4 (1.8) |
2.4 (2.0) |
3.0 (2.5) |
3.01 |
Inpatient/residential | ||||
Alcohol | 2.4 (2.6) | 2.4 (2.6) | 3.0 (2.9) | 1.42 |
Drugs | 0.5 (1.1) |
1.7 (2.3) |
2.1 (2.5) |
5.33 |
Psychiatric | 0.5 (1.1) |
1.7 (2.5) |
2.0 (2.4) |
3.91 |
Mutual-help group history | ||||
Ever attended | 85.7 (24) |
94.7 (162) |
99.0 (104) |
8.85 |
Number of meetings (M, SD) | 95.8 (160.7) | 535.5 (987.2) | 491.0 (1,069.7) | 2.25 |
Number of steps worked (M, SD) | 3.0 (4.4) |
4.8 (4.4) | 5.5 (4.8) |
3.30 |
Involvement (M, SD) | 2.2 (2.9) |
5.2 (3.6) |
5.3 (3.6) |
8.92 |
Functioning | ||||
ASI composites (M, SD) | ||||
Legal | .008 (.038) |
.108 (.174) |
.113 (.180) |
4.59 |
Alcohol | .099 (.164) |
.145 (.200) |
.225 (.248) |
6.06 |
Drugs | .037 (.067) |
.063 (.077) |
.092 (.091) |
6.71 |
Psychological | .340 (.250) |
.382 (.192) |
.442 (.188) |
4.37 |
Employment | .663 (.244) |
.757 (.248) | .788 (.201) |
3.13 |
Family/social | .153 (.118) |
.219 (.173) | .259 (.185) |
4.49 |
Medical | .507 (.383) | .429 (.351) |
.525 (.360) |
2.46 |
Living with someone with (%, |
||||
Alcohol problem | 46.4 (13) |
57.6 (98) |
68.9 (71) |
5.99 |
Drug problem | 42.9 (12) |
58.2 (99) |
67.0 (69) |
5.70 |
Symptoms, lifetime (%, |
||||
Trouble controlling violence | 50.0 (14) |
50.3 (86) |
71.4 (75) |
12.94 |
Serious depression | 85.7 (24) |
96.5 (165) |
97.1 (102) |
5.19 |
Serious anxiety | 89.3 (25) | 92.4 (148) | 96.2 (101) | 2.47 |
Trouble understanding | 82.1 (23) | 66.7 (114) |
83.8 (88) |
11.38 |
Note: means that share a superscript are significantly different at
In addition, patients in the nonviolent and violent arrest groups were more likely than patients in the no-arrest group to have ever attended mutual-help for their substance use disorder and were more involved in 12-step practices. Patients in the violent arrest group had worked more of the 12 steps than patients in the no-arrest group. We conducted additional analyses to determine whether amount of mutual-help group participation differed among the groups when only patients who had attended 12-step meetings were considered. When comparisons were conducted on number of meetings attended, number of steps worked, and involvement using only participants who had ever attended a meeting, patients in the nonviolent (M = 5.5, SD = 3.4) and violent (M = 5.3, SD = 3.6) groups were more involved in 12-step practices than patients in the no-arrest group (M = 2.5, SD = 3.0;
Also as expected, patients in the violent arrest group were most likely to report having had trouble controlling violent behavior in their lifetime. They were also more likely than the nonviolent group to report having had trouble concentrating and understanding. Patients in the two arrest groups were more likely than those in the no-arrest group to have had lifetime symptoms of serious depression.
Six-month characteristics of dually diagnosed patients with no arrests (
Nonviolent | Violent arrests |
|
||
---|---|---|---|---|
No arrests | Arrests | |||
Treatment | ||||
Outpatient | ||||
Any SUD (%, |
57.7 (15) |
79.1 (106) |
79.5 (62) |
5.37 |
Number of SUD sessions (M, SD) | 7.0 (10.2) | 10.4 (12.1) | 9.9 (11.2) | 1.05 |
Inpatient/residential | ||||
Any MH (%, |
14.3 (4) | 23.4 (40) | 18.1 (19) | 1.95 |
Number of MH days (M, SD) | 5.5 (17.4) | 7.4 (23.4) | 6.9 (19.9) | 0.10 |
Any SUD (%, |
11.5 (3) | 23.1 (31) | 20.5 (16) | 1.98 |
Number of SUD days (M, SD) | 2.6 (7.8) | 11.6 (28.0) | 10.0 (26.4) | 1.42 |
Mutual-help groups | ||||
Any attendance | 46.2 (12) |
79.7 (106) |
80.5 (62) |
12.59 |
Number of meetings (M, SD) | 17.5 (33.0) |
56.6 (86.4) |
47.2 (50.3) | 3.26 |
Number of steps worked (M, SD) | 1.2 (2.4) |
3.1 (3.7) |
2.9 (3.6) | 3.04 |
Involvement (M, SD) | 2.7 (3.6) |
6.6 (4.5) |
6.5 (4.4) |
8.95 |
Functioning | ||||
ASI composites (M, SD) | ||||
Legal | .012 (.029) | .054 (.122) | .036 (.110) | 1.81 |
Alcohol | .103 (.133) | .101 (.168) | .109 (.194) | 0.06 |
Drugs | .030 (.033) | .035 (.055) | .034 (.072) | 0.09 |
Psychological | .121 (.049) |
.184 (.135) | .205 (.192) |
3.10 |
Employment | .666 (.254) | .644 (.294) | .656 (.305) | 0.12 |
Family/social | .352 (.211) | .368 (.358) | .358 (.387) | 0.11 |
Medical | .419 (.354) | .351 (.332) | .349 (.366) | 0.58 |
Symptoms, past 30 days (%, |
||||
Trouble controlling violence | 7.7 (2) | 9.7 (13) | 15.6 (12) | 2.01 |
Serious depression | 46.2 (12) | 59.7 (80) | 56.4 (44) | 1.64 |
Serious anxiety | 50.0 (13) | 64.2 (86) | 67.9 (78) | 2.66 |
Trouble understanding | 65.3 (17) | 53.2 (41) | 50.7 (68) | 1.91 |
Note: means that share a superscript are significantly different at
The groups did not differ on whether they had obtained inpatient/residential mental health or SUD treatment, or on the number of days they had obtained such treatment (Table
Regarding mutual-help group utilization, patients in the two arrest groups were more likely to have attended a mutual-help group meeting and were more involved in 12-step practices than patients in the no-arrest group (Table
One-year characteristics of dually diagnosed patients with no arrests (
Nonviolent | Violent arrests |
|
||
---|---|---|---|---|
No arrests | Arrests | |||
Treatment | ||||
Outpatient | ||||
Any mental health (%, |
86.4 (19) | 84.0 (110) | 89.7 (70) | 1.42 |
Number of MH sessions (M, SD) | 13.5 (15.0) | 14.5 (20.2) | 13.1 (17.9) | 0.19 |
Any SUD (%, |
36.4 (8) | 51.9 (68) | 50.0 (39) | 1.84 |
Number of SUD sessions (M, SD) | 4.6 (11.1) | 7.5 (13.7) | 7.1 (23.4) | 0.33 |
Inpatient/residential | ||||
Any mental health (%, |
4.5 (1) | 15.3 (20) | 20.5 (16) | 4.01 |
Number of MH days (M, SD) | 1.0 (3.9) | 5.1 (19.5) | 6.1 (21.1) | 0.76 |
Any SUD (%, |
0.0 (0.0) | 4.6 (6) | 7.7 (6) | 3.32 |
Number of SUD days (M, SD) | 0.0 (0.0) | 2.3 (13.9) | 2.3 (13.3) | 0.40 |
Mutual-help groups | ||||
Any attendance | 47.6 (10) |
71.8 (94) |
67.9 (53) |
4.58 |
Number of meetings (M, SD) | 19.5 (33.7) | 44.9 (68.5) | 41.8 (72.4) | 1.28 |
Number of steps worked (M, SD) | 0.7 (1.6) |
2.6 (3.6) | 2.8 (3.7) |
3.13 |
Involvement (M, SD) | 2.1 (3.2) |
4.9 (4.5) |
4.8 (4.5) |
4.20 |
Functioning | ||||
ASI composites (M, SD) | ||||
Legal | .011 (.001) | .030 (.108) | .029 (.104) | 0.29 |
Alcohol | .052 (.100) | .107 (.170) | .114 (.187) | 1.16 |
Drugs | .014 (.021) | .034 (.062) | .032 (.064) | 1.06 |
Psychological | .329 (.202) | .345 (.210) | .363 (.351) | 0.40 |
Employment | .685 (.237) | .630 (.297) | .672 (.263) | 1.05 |
Family/social | .112 (.057) | .162 (.117) | .172 (.123) | 2.17 |
Medical | .368 (.339) | .378 (.363) | .402 (.358) | 0.15 |
Symptoms, past 30 days (%, |
||||
Trouble controlling violence | 4.7 (1) | 8.7 (11) | 6.0 (5) | 0.39 |
Serious depression | 55.3 (12) | 54.0 (71) | 51.6 (40) | 0.76 |
Serious anxiety | 51.3 (11) | 57.8 (76) | 64.7 (50) | 0.87 |
Trouble understanding | 53.3 (11) | 52.6 (69) | 52.4 (41) | 0.00 |
Note: means that share a superscript are significantly different at
Patients in the arrest groups were more likely to have attended a mutual-help group meeting and to be involved in 12-step practices. In addition, patients in the violent arrest group had worked more steps than patients in the no-arrest group. The greater involvement of the arrested groups held when the comparison was conducted only for patients who had attended a mutual-help group meeting during the follow-up period (Ms, SDs = 5.0 (3.2), 7.8 (3.3), and 8.1 (3.0) for the no arrest, nonviolent arrest, and violent arrest groups, resp.;
Two-year characteristics of dually diagnosed patients with no arrests (
Nonviolent | Violent arrests |
|
||
---|---|---|---|---|
No arrests | Arrests | |||
Treatment | ||||
Outpatient | ||||
Any mental health (%, |
100.0 (21) | 89.6 (121) | 90.0 (72) | 4.32 |
Number of MH sessions (M, SD) | 27.4 (27.8) | 23.2 (32.7) | 23.0 (37.2) | 0.20 |
Any SUD (%, |
33.3 (7) |
60.7 (82) |
61.3 (49) |
5.93 |
Number of SUD sessions (M, SD) | 3.8 (11.6) | 13.4 (28.3) | 15.9 (50.2) | 1.21 |
Inpatient/residential | ||||
Any mental health (%, |
19.0 (4) | 22.2 (30) | 15.0 (12) | 1.72 |
Number of MH days (M, SD) | 5.0 (11.3) | 7.8 (20.9) | 3.7 (12.9) | 1.84 |
Any SUD | 4.8 (1) | 8.9 (12) | 7.5 (6) | 0.51 |
Number of SUD days (M, SD) | 0.3 (1.5) | 2.3 (9.7) | 2.6 (9.9) | 0.68 |
Mutual-help groups | ||||
Any attendance | 38.1 (8) |
70.9 (95) |
67.5 (43) |
8.27 |
Number of meetings (M, SD) | 16.1 (42.3) |
80.1 (137.1) |
60.7 (91.9) | 2.90 |
Number of steps worked (M, SD) | 2.1 (4.3) | 3.6 (4.5) | 3.2 (4.3) | 1.14 |
Involvement (M, SD) | 2.5 (3.8) |
6.2 (4.8) |
5.7 (4.8) |
5.32 |
Functioning | ||||
ASI composites (M, SD) | ||||
Legal | .006 (.001) |
.014 (.069) |
.047 (.136) |
3.17 |
Alcohol | .087 (.132) | .102 (.183) | .114 (.193) | 0.24 |
Drugs | .030 (.070) | .029 (.058) | .026 (.065) | 0.09 |
Psychological | .350 (.219) | .341 (.216) | .310 (.229) | 0.63 |
Employment | .712 (264) | .628 (.301) | .679 (.286) | 1.49 |
Family/social | .144 (.071) | .160 (.133) | .175 (.152) | 0.52 |
Medical | .442 (.379) | .347 (.332) | .437 (.345) | 2.31 |
Symptoms, past 30 days (%, |
||||
Trouble controlling violence | 9.5 (2) | 11.3 (15) | 16.3 (13) | 1.30 |
Serious depression | 38.1 (8) | 47.5 (38) | 50.7 (68) | 1.22 |
Serious anxiety | 61.9 (13) | 58.2 (78) | 58.8 (47) | 0.10 |
Trouble understanding | 57.1 (12) | 50.0 (66) | 43.8 (35) | 1.47 |
Note: means that share a superscript are significantly different at
Patients in the arrest groups were more likely to attend a mutual-help group and be more involved in 12-step practices (Table
At the two-year follow-up, when arrest status was controlled, concurrent analyses found more severe drug (
In this sample of dually diagnosed patients beginning an episode of VA outpatient mental health treatment, 91% had a history of at least one arrest. Of patients with an arrest history, 38% had been arrested for a violent offense. Compared to other samples of both VA and non-VA treated patients, the arrest rate in our sample is higher, but the rate of violent offenses is similar [
Similar to previous research comparing violent and nonviolent offenders and nonoffenders, this study of dual diagnosis patients found both differences and similarities between the violent and nonviolent groups at intake to treatment. At baseline, the violent arrest group was more severe than the nonviolent and no-arrest groups in that they had more outpatient treatment episodes for psychiatric problems and poorer functioning in the psychiatric, alcohol, and drugs domains; they were also more likely to live with someone with substance use problems. In addition, the violent arrest group was more severe than the no-arrest group by reporting poorer functioning in the employment and family/social domains and more lifetime serious depression. In contrast to these results showing the severity of the violent arrest group in particular, both of the arrest groups—violent and nonviolent—had more inpatient and residential treatment episodes for drug and psychiatric problems prior to the episode beginning at baseline. The two arrest groups were also more likely to have ever attended a mutual-help group and were more involved in 12-step practices than the no-arrest group.
Previous studies also reported violent and nonviolent offenders to be similar on some aspects of treatment and functioning but different on others. Offenders were more likely to have used mental health services prior to their first criminal sentence than a matched community group of nonoffenders, and violent offenders were more likely to have used mental health services than nonviolent offenders [
In keeping with their greater severity at baseline, at the 6-month follow-up, more patients in the violent and nonviolent arrest groups had obtained SUD outpatient treatment and attended a mutual-help group meeting than patients in the no-arrest group, and the arrested groups were more involved in 12-step practices. The higher likelihood of SUD treatment or mutual-help group attendance and involvement by the arrested groups continued at the one- and two-year follow-ups. Both treatment providers and patients themselves appear to have responded appropriately to the greater severity of the arrested groups [
The violent arrest group had poorer psychological functioning than the no-arrest group did at six months after intake and poorer legal functioning than the no-arrest and nonviolent arrest groups at two years after intake. However, generally, the three groups were comparable on functioning at follow-ups when baseline functioning was controlled. Our findings that dually diagnosed patients with a history of violent arrest were generally similar to initially less severe groups on treatment outcomes are encouraging in that treatment seemed to be responsive to the needs of patients reporting violence perpetration [
When arrest status was controlled, milder drug and psychological problems at the two-year follow-up were associated with milder legal problems at the same time point [
Although this study had a number of strengths, such as a large, unselected dually diagnosed sample with high follow-up rates over two years and the use of medical records to obtain treatment utilization data, it also had some limitations. All patients were treated within the VA, which is federally funded and operates the largest mental health treatment system in the US. Generally, VA health services are of similar quality and effectiveness to those in the private sector [
The use of an observational design, rather than a randomized controlled trial design, also has strengths and weaknesses. We could not randomly assign participants to different arrest histories, and we chose to not randomly assign participants with similar or different arrest histories to different types or amounts of treatment (or recommended mutual-help group participation) because our focus was on examining outcomes obtained in routine practice. We also chose to report outcomes reflecting short- (6 months), medium- (one year), and long-term (two years) follow-ups, to optimize the practical utility of the findings for treatment providers facilitating pathways to recovery and desistance. Such reporting is also in keeping with requirements for potential systematic reviews and meta-analyses in which results from more than one timepoint cannot be combined without a unit-of-analysis error. In addition, our data were based on self-report, which may provide opportunity for less-than-accurate self-disclosure. However, comparisons of self-reports of arrests and official records have concluded that self-reports are valuable for research [
Addiction and mental health treatment providers recognize that they are involved in the risk management of patients who might pose a threat to public health and safety through engagement in violence [
The authors declare that they have no competing interests.
Dr. Timko was supported by VA HSR&D (RCS 00-001), Dr. Blonigen by VA CSR&D (CDA-2 008-10S), and Dr. Finlay by VA HSR&D (CDA-2 13-279).