Improving Treatment Engagement and Outcomes among Justice-involved Veterans

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 DESCRIPTION (provided by applicant): 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. 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: Aim 1: A total of 365 Veterans who are being admitted to an MH RRTP, and had been arrested and charged and/or released from incarceration in the past 12 months, will complete a baseline assessment, be randomized to MRT or usual care (UC), and followed at 6 and 12 months post-baseline. Hypotheses: Those in the MRT (vs. the UC) condition, will (1a) have a lower overall risk for criminal recidivism; (1b) have better health-related outcomes (substance use, mental health, housing, and employment); and (1c) the effects of MRT on reduced risk for recidivism and better health-related outcomes will be mediated in part by greater likelihood of completing the MH RRTP and utilizing substance use disorder and mental health continuing care services. Aim 2: Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we will conduct qualitative interviews with 6 providers and 12 patients at each study site to identify (2a) barriers and facilitators to implementation of MRT in MH RRTPs across VA, and (2b) whether and/or how to adapt MRT to be most effective with diverse subpopulations of Veterans (e.g., OEF/OIF Veterans; women; racial/ethnic minorities; those with PTSD). Given that VA has not systematically implemented interventions that address antisocial cognitions and behaviors, this project fills a substantial gap in care for JIVs in VA, and therefore has significant potential to improve the long-term health of this vulnerable population. Accordingly, it has strong support from VACO operational partners (VJP and Mental Health Services) and three HSR&D Centers of Innovation.