Challenges and Lessons Learned in the Regional Implementation of MISSION-CJ in Drug Treatment Courts

Adult drug treatment courts (ADTCs) were developed to reduce drug-related incarceration by providing a rehabilitative sentencing alternative for people with substance use disorders who are facing substance use–related charges (1). In 2019, approximately 1.6 million people in the United States had an opioid use disorder, and 10.1 million reported opioid misuse (2). Mirroring national trends, Erie County, New York, experienced rapidly rising opioid overdose rates, doubling between 2014 and 2015 (from 12.2 to 25.9 per 100,000 population) (3). A local critical time intervention (CTI) pilot program (4) providing case management in the ADTCs identified limitations of the traditional ADTC model among people with opioid use disorder, who represented a growing proportion of drug court participants. Specifically, no mechanism was in place to quickly identify and engage participants at risk for overdose. In addition, limited attention was paid to co-occurring mental health problems. Stakeholders agreed that a more dynamic approach was needed to facilitate rapid treatment linkage while integrating behavioral health and medical needs.

In response, a 3-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) was awarded to the Erie County Department of Mental Health (ECDMH) in 2016. ECDMH contracted with the State University of New York (SUNY) to provide the evidence-based MISSION-CJ (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking–Criminal Justice) (5) intervention to ADTC participants, focusing on individuals at high risk for opioid overdose. The goal was regional implementation of the MISSION-CJ intervention across eight drug treatment courts within the Eighth Judicial District. This intervention was chosen because its emphasis on addressing co-occurring disorders met participants’ needs. CTI is a core component of the MISSION-CJ model (along with dual-recovery therapy, peer support, vocational support, and trauma-informed care considerations), making MISSION-CJ a natural extension of the existing CTI pilot program (6).

The MISSION-CJ intervention was offered to a subset of ADTC participants with co-occurring substance use and mental health conditions and at high risk for opioid overdose and who had been identified by the courts or the MISSION-CJ team. MISSION-CJ teams, consisting of a case manager and a peer support specialist, worked across the eight courts, spending 1 day per week at each court’s ADTC session and managing caseloads of ≤20 participants at a time. In total, 363 individuals received services during the grant period. Unpublished reports generated from SAMHSA-required GPRA (Government Performance and Results Act) data indicated improvements among participants over 6 months, including improvements in clients reporting alcohol and drug abstinence (27.6% increase), no past 30-day arrests (5.7% increase), employment or educational engagement (53.6% increase), and housing stability (12.3% increase), as well as reductions in risky behaviors such as injection drug use (71.4% decrease) and unprotected sexual activity (15.4% decrease).

Further, the program data suggested that the MISSION-CJ intervention addressed overdose risk. During enrollment in the intervention, 329 participants reported past or current use of opioids. Of those, 207 (63%) were further assessed and deemed at risk for overdose, and of those, 129 (62%) were linked to medication-assisted treatment. To the best of our knowledge, only six (3%) of the assessed participants experienced an overdose during their time in the MISSION-CJ intervention. Although we could not directly compare the intervention outcomes with those of a treatment-as-usual group, these data suggest improved outcomes among the individuals in the MISSION-CJ cohort, despite the challenges and required adaptations made during the implementation of MISSION-CJ, as outlined in the following.

CTI

The CTI model is a time‐limited intervention, bridging the gap between services during times of transition and featuring three distinct phases of decreasing intensity, low caseloads, and treatment plans focusing on one to three goals per phase (7). Previously, the courts provided limited case management that linked participants to services required for program completion. The existing Court Outreach Unit: Referral and Treatment Services (COURTS) program comprises provider representatives acting as part of the court team. Many treatment providers are present to obtain referrals specifically to their services and may collaborate with other onsite service providers to varying degrees.

In contrast to the limited court-provided case management, the CTI model provides integrated person-centered care coordination across all services to comprehensively address client needs, with particular attention to co-occurring mental health and substance use needs. MISSION-CJ teams facilitated connections to services for mental and general medical health care, medication-assisted treatment, and social services. MISSION-CJ staff act in complement to the court but are not embedded within the court as is the case with the COURTS providers. Although MISSION-CJ teams contributed to case reviews, communicated with the judge and court staff, and advocated at the bench during session, they were not solely working on behalf of the court or a treatment provider; rather, they worked primarily for the client, to provide a collaborative and integrated intervention.

Retaining participants in case management for the duration of CTI was challenging. Although many participants received some services, many did not complete all three CTI phases. To improve retention, the program trained all MISSION-CJ staff in engagement and retention strategies. Comprehensive information about the client and close contacts gave the team more outreach options, including telephone numbers, addresses, social media accounts, relatives’ information, hang-out locations, and other relevant information. This approach resulted in increased engagement and retention.

Dual-Recovery Therapy

In addition to an emphasis on co-occurring behavioral and substance use disorders throughout all components, the MISSION-CJ model explicitly addresses co-occurring disorders through dual-recovery therapy. Case managers deliver 13 weekly structured psychoeducational sessions, ideally in the first phase of CTI. Drug treatment courts typically require participants to attend only substance use counseling. However, participants often have other unaddressed co-occurring behavioral health needs. Although court teams screen for behavioral health diagnoses, they require treatment for behavioral health or co-occurring disorders only in some circumstances.

Drug court research has documented participants’ complaints that mental health needs are underaddressed, as well as related concerns that mental health problems might precipitate future substance use (8). Dual-recovery therapy was designed to assess motivational level, help track troublesome symptoms, and explore medication needs and compliance. Using a combination of cognitive-behavioral therapy and skills building, dual-recovery therapy develops skills for recovery and understanding of the relationships among co-occurring disorders.

The MISSION-CJ teams found it difficult to deliver dual-recovery therapy sessions with fidelity upon client enrollment in the program. Many clients reported feeling overwhelmed by having multiple court obligations and a weekly therapy commitment. For clients who did engage in therapy, it was difficult to deliver all 13 sessions on a regular weekly schedule. To overcome this challenge, the MISSION-CJ team delayed the start of dual-recovery therapy to respect clients’ concerns and prioritize developing therapeutic alliances. Weekly sessions were encouraged, but clients were given the agency to decide when sessions were delivered, resulting in more treatment engagement and increased curriculum completion. Although many clients reported positive experiences with dual-recovery therapy, it may not be necessary for everyone—many participants who did not engage in dual-recovery therapy still completed the program with improved outcomes.

Peer Support

The peer support services component complements and reinforces CTI and dual-recovery therapy by providing support from someone with previous experience of mental health or substance use disorders (5). Although some courts engage peer-run agencies that participate in clients’ case management, this practice is not standard. Court-based peers may offer support and assistance across a spectrum of services. The MISSION-CJ peer model is designed to offer clients prosocial support, activities, and modeling; encourage and educate regarding self-help; encourage compliance with court requirements; and provide 11 structured peer-led weekly sessions focused on managing co-occurring disorders. All participants receive a peer support specialist who works with them throughout the intervention.

Recruiting and retaining peer support specialists presented another significant challenge. We initially believed that having peers who shared the program participants’ demographic characteristics (i.e., younger White men with opioid use disorder) would be helpful in developing relationships with participants. However, because of their inexperience and the relative recency of their own recovery (approximately 2 years), these peers had trouble maintaining boundaries with participants. They developed relationships that were harmful to them (both relapsed while employed), the participants (for whom they were role models), and the program (by creating challenges with the courts, participants, and the community).

Subsequently, we chose a candidate with many years of experience in peer support who was very stable in her recovery (18 years) and had experience working with community-based organizations and supervising other peers. Despite differing in demographic characteristics from most of the other clients (an older Black woman whose drug of choice had been crack cocaine), she has had the most impact on meaningful engagement. For example, with regard to implementing the structured peer support sessions, she was more comfortable initiating sessions, had much more lived experience to draw on, was more successful in maintaining regular session attendance, and was able to link participants to more meaningful prosocial activities and services. Although she took on the workload of two peer support specialists, because of her wealth of knowledge regarding community services, a large network of peer colleagues, and years of experience in the field, she could effectively manage the caseload alone across all courts.

Vocational Support

Vocational and educational support and linkage to community-based supports is another MISSION-CJ component. Courts often have resources and representatives for linking clients to educational and vocational services such as high school education classes, commercial driver’s license training, and the local community college. MISSION-CJ teams work to establish these linkages but also to identify clients’ needs, strengths, and desires with regard to employment and education. The care team focuses on practical barriers such as transportation, professional etiquette, and interviewing skills. Clients are supported throughout the whole process with coaching, resources, and problem solving.

Some difficulties were encountered in linking clients to employment services because some courts discourage work or other activities that are unrelated to recovery in the early program phases. Also, clients reported being overwhelmed with court menu requirements and lifestyle changes. Many participants were on disability and could not or did not want to work. For those who did seek work, their criminal record sometimes posed a formidable barrier in efforts to find employment. In other instances, more pressing needs, such as housing and care for chronic comorbid disease, took precedence. As a result, education and employment were often lower on the priority list. Even when vocational and educational goals were not a primary focus of the care plan, identified needs and goals were addressed, and clients were given resources for future consideration when they felt ready.

Clients receiving Social Security benefits who wanted to find work were linked with a peer who provided benefits counseling and educated them about earning limits. Clients were provided with lists of employers who hire individuals with criminal records and were linked to education services that provided intensive 5-day training designed specifically for individuals with a criminal record who were seeking employment or education.

Trauma-Informed Care Considerations

Trauma-informed care considerations are the final primary component of the MISSION-CJ model. In addition to the promotion of trauma-informed principles by the National Association of Drug Court Professionals, most Eighth Judicial District courts had previously received basic trauma education from the Institute on Trauma and Trauma-Informed Care (at SUNY-Buffalo), but implementation of trauma-informed principles was inconsistent. MISSION-CJ teams recognized that criminal justice settings were often still triggering for participants. To avoid retraumatizing participants, MISSION-CJ teams worked with the courts to reinforce their understanding of trauma-informed principles. Care teams also worked with clients to prepare them for potential triggers and to practice coping skills in preparation for challenging court sessions. Finally, MISSION-CJ teams were trained to screen for trauma-related symptoms and refer clients to trauma-specific providers when needed. Overall, the goal of these activities was to enhance trauma awareness among both the courts and participants and empower clients by creating opportunities to rebuild a sense of choice and control.

Conclusions

Our experiences implementing the evidence-based MISSION-CJ program regionally across multiple drug treatment court programs illuminate key challenges and solutions around each intervention component. In addition to the aforementioned strategies, we found stakeholder support to be key to implementation success. Strong relationships among the ECDMH, SUNY, the Eighth Judicial District courts, and community-based service providers were critical. The district’s chief judge was engaged in ongoing learning and site visits to ensure support for evidence-based practices. Quarterly stakeholder meetings were held to ensure that policy, operations, and quality control measures were being enforced.

Through the implementation process, we learned that strong upfront training of MISSION-CJ staff and court personnel regarding the model, evidence-based practice, and the importance of program evaluation were invaluable for monitoring and documenting progress. Certain components of MISSION-CJ, such as the CTI, the trauma-informed approach, and the more informal components of peer support were valuable for all clients; other components, however, such as the dual-recovery therapy, structured peer sessions, and employment support, were more challenging, and programs will need to develop criteria to target these services to the individuals most suited to benefit from them. While implementing this evidence-based model, the MISSION-CJ team could adapt elements in real time to develop programming tailored for each client. Ongoing research and quality improvement work is needed to test MISSION-CJ outcomes and variations in its components, content, and program delivery to optimize both client outcomes and efficient implementation in diverse criminal justice settings. Programs can enhance success among drug court participants with the MISSION-CJ model but may need to be flexible with regard to implementation fidelity and may need to work on establishing and communicating their specific role within the court.