The Development of a Substance Abuse Treatment Program for Forensic Patients with Cognitive Impairment

Article excerpt

The Substance Abuse and Mental Illness (SAMI) program combines cognitive rehabilitation and dual-diagnosis substance abuse treatment within a stages of change context. This article describes the development, implementation, and preliminary outcome analysis of the SAMI program in a forensic hospital.


Counselors in forensic psychiatric treatment settings typically provide intensive substance abuse treatment to their patients and frequently need to do so as a condition of discharge to a less restrictive environment (Beck, 2002; Ogloff, 2004; Wheatley, 1998). Given the high comorbidity rates (from 15% to 70%) between substance abuse and severe psychiatric disorders (e.g., schizophrenia; Greenfield, Weiss, & Tohen, 1995; Lehman, Myers, Corty, & Thompson, 1994; Soni et al., 2005; Storch, 1992), substance abuse counseling has been demonstrated to be an important and effective intervention for this population (Brower, Blow, & Beresford, 1989; K. B. Carey, Purnine, Maisto, Carey, & Simons, 2000; Cimino, 2002; Kaufman, 1989; Leach, Hardy, & Dinwiddie, 1998; Levy, 2002; Levy & Mann, 1988; Mowbray et al., 1995). However, when providing addictions counseling to individuals with severe mental illness, counselors must determine which interventions are appropriate for their patients given limitations in cognitive ability (Brower et al., 1989; K. B. Carey et al., 2000; Cimino, 2002; Kaufman, 1989; Leach et al., 1998; Levy, 2002; Levy & Mann, 1988; Mowbray et al., 1995) and social functioning (K. B. Carey & Carey, 1990; Van Horn, 2000) that can accompany psychiatric disorders such as schizophrenia. Social skills training has also been shown to be an effective intervention for remediating social skills deficits among individuals with schizophrenia (Bellak, Mueser, Gingerich, & Agresta, 1997). Therefore, a skills-training approach could feasibly be implemented by counselors for the treatment of substance abuse among dually diagnosed individuals with severe mental illnesses.

This article describes a program that was recently developed for providing intensive skills-based substance abuse treatment to a population of forensically committed patients with severe mental illness and limitations in cognitive functioning. The article also describes the rationale for developing such a program and some of the obstacles that were encountered along the way. Additionally, the article describes a skills-training approach that can be used by counselors in similar settings and discusses methods for integrating cognitive rehabilitation strategies into counseling interventions. Finally, preliminary outcome data are presented and suggestions are provided for counselors and administrators who wish to develop similar programs at other facilities.

Rationale for the Approach

The program discussed in this article was implemented at a 1,500-bed maximum-security hospital for judicially committed forensic patients on the West Coast of the United States. (The hospital's name and location have been withheld to ensure confidentiality.) The hospital treats patients with different judicial commitments, the bulk of whom are committed as "not guilty by reason of insanity" or as "incompetent to stand trial" or are committed under the state's Mentally Disordered Offender statute. The vast majority of the patients at the hospital have been diagnosed with severe mental illnesses such as schizophrenia, bipolar disorder, or schizoaffective disorder. In addition, a large percentage of patients admitted to the hospital also have been diagnosed with an Axis II disorder, most frequently antisocial personality disorder. The most prevalent secondary diagnosis among the patients with mental illness at the hospital is substance abuse or dependence, and many of the crimes leading to their incarceration occurred while under the influence of substances. Not surprisingly, a significant treatment focus at the hospital has been targeting substance abuse relapse prevention. …