Adapting judicial supervision to the risk level of drug offenders: discharge and 6-month outcomes from a prospective matching study. A randomized trial of a DWI intervention program for first offenders: intervention outcomes and interactions with antisocial personality disorder among a primarily American-Indian sample. Substance abuse and personality disorders in homeless drop-in center clients: symptom severity and psychotherapy retention in a randomized clinical trial. Differential effects of manual assisted cognitive behavior therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study. Social problem-solving plus psychoeducation for adults with personality disorder: pragmatic randomised controlled trial. The effect of a case management intervention on drug treatment entry among treatment-seeking injection drug users with and without comorbid antisocial personality disorder. Therapist success and its determinants. Cognitive behaviour therapy for violent men with antisocial personality disorder in the community: an exploratory randomized controlled trial. A behavioral treatment for opioid-dependent patients with antisocial personality. Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions.
This article reports recent findings from a program of experimental research examining the effects of adapting judicial supervision to the risk level of drug-abusing offenders. Prior studies revealed that high-risk participants with (1) antisocial personality disorder or (2) a history of drug abuse treatment performed significantly better in drug court when they were scheduled to attend frequent, bi-weekly judicial status hearings in court. Low-risk participants performed equivalently regardless of the schedule of court hearings. The current study prospectively matched misdemeanor drug court clients to the optimal schedule of court hearings based upon an assessment of their risk status, and compared outcomes to those of clients randomly assigned to the standard schedule of court hearings. Results confirmed that high-risk participants graduated at a higher rate, provided more drug-negative urine specimens at 6 months post-admission, and reported significantly less drug use and alcohol intoxication at 6 months post-admission when they were matched to bi-weekly hearings as compared to the usual schedule of hearings. These findings yield practical information for enhancing the efficacy and cost-efficiency of drug court services. Directions for future research on adaptive programming for drug offenders are discussed. Randomized trial evidence on the effectiveness of incarceration and treatment of first-time driving while intoxicated (DWI) offenders who are primarily American Indian has yet to be reported in the literature on DWI prevention. Further, research has confirmed the association of antisocial personality disorder (ASPD) with problems with alcohol including DWI.
                A randomized clinical trial was conducted, in conjunction with 28 days of incarceration, of a treatment program incorporating motivational interviewing principles for first-time DWI offenders. The sample of 305 offenders including 52 diagnosed as ASPD by the Diagnostic Interview Schedule were assessed before assignment to conditions and at 6, 12, and 24 months after discharge. Self-reported frequency of drinking and driving as well as various measures of drinking over the preceding 90 days were available at all assessments for 244 participants. Further, DWI rearrest data for 274 participants were available for analysis.
                Participants randomized to receive the first offender incarceration and treatment program reported greater reductions in alcohol consumption from baseline levels when compared with participants who were only incarcerated. Antisocial personality disorder participants reported heavier and more frequent drinking but showed significantly greater declines in drinking from intake to posttreatment assessments. Further, the treatment resulted in larger effects relative to the control on ASPD than non-ASPD participants.
                Nonconfrontational treatment may significantly enhance outcomes for DWI offenders with ASPD when delivered in an incarcerated setting, and in the present study, such effects were found in a primarily American-Indian sample. This study evaluated the psychiatric symptoms, psychosocial problems, and treatment response of personality-disordered substance abusers receiving services within a homeless drop-in center. Fifty-two homeless clients were assessed after program admission and randomly assigned to receive either individual psychotherapy focused on personality disorder and substance abuse relapse prevention (dual-focus schema therapy [DFST]) or standard group substance abuse counseling (SAC). Client functioning was assessed using measures of personality disorder, psychiatric symptoms, early maladaptive schemas, interpersonal problems, and addiction-related psychosocial impairment. Therapy retention (total weeks in treatment) and utilization (number of weeks in which sessions were attended) were the primary outcomes. Although rates of cluster B personality disorders were comparable to other substance dependent samples, clusters A and C disorders were disproportionately more common. Clients reported significant psychiatric symptoms, criminality, and psychosocial impairment, yet made limited lifetime use of mental health services. Overall, there was greater utilization of individual DFST than group SAC. However, clients with more severe personality disorder symptoms demonstrated better utilization of SAC than DFST. A total of 480 patients were treated in a large, multicenter randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behavior therapy (MACT) versus treatment as usual (TAU) for recurrent deliberate self-harm. Each patient was randomized after a self-harm episode assessed at an accident and emergency center and followed up over 1 year. The main hypothesis tested was that those allocated to MACT would have a lower proportion of self-harm episodes in the succeeding year. A total of 60% of those allocated to MACT had face-to-face treatment and 430 (90%) of all patients had self-harm data recorded after 1 year. Although the results showed no significant difference between those repeating self-harm in the MACT group (39%) compared with the TAU group (46%) (P = 0.20), the treatment was cost effective (10% cheaper than TAU) and the frequency of self-harm episodes was fewer (50%) in the MACT group. A total of nine of 10 patients had some personality disturbance (42% of these with disorder), and for those where information on parasuicide events was collected, the proportion having a repeat episode ranged from 33% to 63% for different personality disorders. Those with BPD were most likely to repeat episodes quickly (mean 89 days for 25% to repeat) with dissocial personality disorder (equivalent mean 384 days) the slowest to repeat. Total costs were significantly greater in those with personality disorder and were reduced in those allocated to MACT; this saving was reversed in those with borderline disorder. On average, MACT appeared to increase the cost of those patients with BPD (BPD) and reduce the cost of those with other personality disorders. It is concluded that MACT has value in preventing self-harm cost effectively but this appears to be confined mainly to those who do not have BPD. Social problem-solving therapy may be relevant in the treatment of personality disorder, although assessments of its effectiveness are uncommon.
                To determine the effectiveness of a problem-solving intervention for adults with personality disorder in the community under conditions resembling routine clinical practice.
                Participants were randomly allocated to brief psychoeducation plus 16 problem-solving group sessions (n=87) or to waiting-list control (n=89). Primary outcome was comparison of scores on the Social Problem Solving Inventory and the Social Functioning Questionnaire between intervention and control arms at the conclusion of treatment, on average at 24 weeks after randomisation.
                In intention-to-treat analysis, those allocated to intervention showed significantly better problem-solving skills (P<0.001), higher overall social functioning (P=0.031) and lower anger expression (P=0.039) compared with controls. No significant differences were found on use of services during the intervention period.
                Problem-solving plus psychoeducation has potential as a preliminary intervention for adults with personality disorder. We examined the effect of a case management intervention on drug treatment entry among injection drug users (IDUs) with and without comorbid antisocial personality disorder (ASPD). Injection drug users attending the Baltimore Needle Exchange Program who sought and were granted referrals to opioid agonist treatment were randomized to receive a strengths-based case management intervention or passive referral. Of 162 IDUs, 22.8% met the DSM-IV criteria for ASPD. Compared to those without ASPD, IDUs with comorbid ASPD who spent 25 or more minutes with their case manager prior to their treatment entry date were 3.51 times more likely to enter treatment than those receiving less than 5 min, adjusting for intervention status, race, and treatment site (95% confidence interval 1.04-11.89). Providing case management services to IDUs with comorbid ASPD may facilitate treatment entry and reduce the negative consequences of drug abuse. This study examined the relatively unexplored contribution of the therapist's performance in determining outcomes of treatment. Nine therapists were studied: three performed supportive-expressive psychotherapy; three, cognitive-behavioral psychotherapy; and three, drug counseling. Profound differences were discovered in the therapists' success with the patients in their case loads. Four potential determinants of these differences were explored: patient factors; therapist factors; patient-therapist relationship factors; and therapy factors. Results showed that patient characteristics within each case load (after random assignments) were similar and disclosed no differences that would have explained the differences in success; therapist's personal qualities were correlated with outcomes but not significantly (mean r = .32); an early-in-treatment measure of the patient-therapist relationship, the Helping Alliance Questionnaire, yielded significant correlations with outcomes (mean r = .65); among the therapy techniques, "purity" provided significant correlations with outcomes (mean r = .44), both across therapists and within each therapist's case load. The three therapist-related factors were moderately associated with each other. Little information exists on treatment effectiveness in antisocial personality disorder (ASPD). We investigated the feasibility and effectiveness of carrying out a randomized controlled trial of cognitive behaviour therapy (CBT) in men with ASPD who were aggressive.
                This was an exploratory two-centre, randomized controlled trial in a community setting. Fifty-two adult men with a diagnosis of ASPD, with acts of aggression in the 6 months prior to the study, were randomized to either treatment as usual (TAU) plus CBT, or usual treatment alone. Change over 12 months of follow-up was assessed in the occurrence of any act of aggression and also in terms of alcohol misuse, mental state, beliefs and social functioning.
                The follow-up rate was 79%. At 12 months, both groups reported a decrease in the occurrence of any acts of verbal or physical aggression. Trends in the data, in favour of CBT, were noted for problematic drinking, social functioning and beliefs about others.
                CBT did not improve outcomes more than usual treatment for men with ASPD who are aggressive and living in the community in this exploratory study. However, the data suggest that a larger study is required to fully assess the effectiveness of CBT in reducing aggression, alcohol misuse and improving social functioning and view of others. It is feasible to carry out a rigorous randomized controlled trial in this group. Antisocial personality disorder (APD) is associated with increased problem severity in treatment-seeking opioid-dependent patients. Treatment studies have reported mixed results but generally show that patients with APD make progress that is often comparable to drug-dependent patients without the personality disorder. Much of this work is based on secondary analyses of studies evaluating responses to a variety of drug abuse treatment interventions. This study reports on a randomized prospective trial evaluating a behavioral approach for managing opioid-dependent patients with APD. Subjects (N = 100) met Diagnostic and Statistical Manual of Mental Disorders criteria for opioid dependence and APD using a structured clinical interview and were randomly assigned to either an experimental condition (n = 51), which used a highly structured contingency management intervention, or a control condition (n = 49), which reflected standard methadone treatment. Subjects in the experimental group had significantly better counseling attendance and some indication of lower psychosocial impairment compared to the control group. The experimental intervention increased attendance in subjects with low and high levels of psychopathy and with and without other psychiatric comorbidity. These findings support the development of interventions more tailored to drug-dependent patients with APD. This study compared the efficacy of 2 approaches for the treatment of cocaine dependence among methadone-maintained patients with and without antisocial personality disorder (ASPD). Patients were randomly assigned to 4 study conditions: cognitive-behavioral treatment (CBT), contingency management (CM), CBT with CM, or methadone maintenance. The Structural Clinical Interview for Mental Disorders-IV was administered to 108 patients to assess ASPD. A 2-way analysis of variance showed that patients with ASPD were more likely to abstain from cocaine use during treatment than patients without ASPD. The strong treatment effect for ASPD patients was primarily due to the CM condition. Regression analyses showed that ASPD remained significantly related to CM treatment responsivity while controlling for other factors.