Improving Treatment Engagement and Outcomes among Justice-involved Veterans

 描述(由申请人提供)： 每年约有146 000名退伍军人从惩教场所获释；然而，三分之二的人可能会重新犯罪并重返司法系统。反社会认知和行为是再次犯罪的最强预测因素，在涉及正义的退伍军人中非常普遍。然而，在缺乏证明有效的联合免疫治疗的情况下，退伍军人管理局还没有实施系统的方法来解决反社会认知和行为。道德重建疗法(MRT)是一种旨在减少反社会认知和行为的认知行为干预。MRT在降低平民罪犯的犯罪累犯风险方面具有最佳的经验支持，其相关机制(改善人际功能和冲动控制)与改善与健康相关的结果有关，这些结果也是累犯的风险因素(药物使用、精神健康、住房和就业问题)。然而，还没有对联合免疫接种进行试验。JIV和参与司法的平民之间的差异(例如，创伤性脑损伤的患病率；人际问题)表明，先前关于平民MRT的研究可能不能一概而论，并促使退伍军人司法方案(VJP)和MRT的开发者开发这种干预的退伍军人专用课程。测试这本新的捷运老手手册是VJP的首要任务。使用新的退伍军人专用手册，当前提案的首要目标是实施和评估MRT作为一种干预措施，以降低退伍军人精神卫生康复治疗计划(MH RRTP)中的JIV再次犯罪的风险，并改善与健康相关的结果。使用混合类型1设计，该项目将在多站点RCT(帕洛阿尔托、小石城和贝德福德)中测试MRT的有效性，并进行形成性评估，以促进未来在弗吉尼亚州实施MRT：目标1：共有365名退伍军人进入MH RRTP，并在过去12个月内被捕、被起诉和/或出狱，他们将完成基线评估，被随机分配到MRT或常规护理(UC)，并在基线后6个月和12个月进行跟踪。假设：MRT(与UC相比)的患者将(1a)有较低的犯罪再犯总体风险；(1b)有更好的与健康相关的结果(物质使用、精神健康、住房和就业)；以及(1c)MRT在降低再犯风险和更好的健康相关结果方面的效果将部分地通过完成MH RRTP和利用物质使用障碍和精神健康持续护理服务的可能性来调节。目的2：利用REACH，Efficiency，Adption，Implementation，and Maintenance(RE-AIM)框架，我们将在每个研究地点对6个提供者和12名患者进行定性访谈，以确定(2a)在退伍军人中实施MRT的障碍和促进者，以及(2b)是否和/或如何使MRT对不同的退伍军人群体(例如，OEF/OIF退伍军人；女性；种族/少数民族；患有创伤后应激障碍的人)最有效。鉴于退伍军人管理局没有系统地实施针对反社会认知和行为的干预措施，该项目填补了退伍军人管理局在照顾儿童感染儿童方面的重大空白，因此具有改善这一弱势群体长期健康的巨大潜力。因此，它得到了VACO运营合作伙伴(VJP和精神健康服务)和三个HSR&D创新中心的大力支持。

 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.