Residential Treatment Program Research Articles

An Evaluation Study of the “RESTART” Program—Short-Term Residential Treatment for Addiction

The syndrome model of addiction argues that addiction should be conceptualized as a syndrome with multiple opportunistic expressions. The model is built on the observation that despite the various manifestations of addictive behaviors, they share many commonalities in terms of the etiology and the associated consequences. This model proliferates the understanding of the high relapse rate in addiction after receiving solely symptom-focused treatment. For clinicians, this conceptual model emphasizes the importance of in-depth multidimensional assessment and treatment modality for the interacting underpinnings of addictions. In Hong Kong, very few residential services are currently provided for clients with addictive behaviors other than substance abuse. Against this background, we developed a pilot short-term residential treatment program namely “RESTART” based on the Acceptance Commitment Therapy and Expressive Arts Therapy for clients with various expressions of addiction. The program contained a 4-day and 3-night overnight residential treatment camp followed by three post-camp workshops, and a full-day camp. It aimed to help participants rebuild a positive lifestyle and raise self- efficacy and coping abilities. The program recruited 44 participants with various expressions of addiction including gambling disorder, sex addiction, compulsive buying, compulsive stealing, internet gaming disorder, alcohol, and cigarette addiction. The program evaluation focused on six outcomes, including health consciousness, motivation to build a healthy life, psychological distress, disclosure of distress, perceived emotional and life disturbance by addiction, and self-efficacy of urge management. Quasi-experimental design was adopted to compare the experimental group (program participants) and the control group with similar demographic and addiction backgrounds. They were surveyed in four intervals in which pretest before the commencement of the residential program was conducted to compare with posttest at the program endpoint and two follow-up tests in 3 months after the program. Repeated-measures general linear models indicated that relative to the control participants, the experimental participants yielded significant increase in willingness to disclose distress and self-efficacy over time, whereas their perceived disturbance by addiction significantly reduced over time. These results suggest that the residential treatment camp is a potentially promising complement to treatment for diverse addiction problems.

A comparative network analysis of eating disorder psychopathology and co-occurring depression and anxiety symptoms before and after treatment.

Network analysis is an emerging approach in the study of psychopathology, yet few applications have been seen in eating disorders (EDs). Furthermore, little research exists regarding changes in network strength after interventions. Therefore the present study examined the network structures of ED and co-occurring depression and anxiety symptoms before and after treatment for EDs. Participants from residential or partial hospital ED treatment programs (N = 446) completed assessments upon admission and discharge. Networks were estimated using regularized Graphical Gaussian Models using 38 items from the Eating Disorders Examination-Questionnaire, Quick Inventory of Depressive Symptomatology, and State-Trait Anxiety Inventory. ED symptoms with high centrality indices included a desire to lose weight, guilt about eating, shape overvaluation, and wanting an empty stomach, while restlessness, self-esteem, lack of energy, and feeling overwhelmed bridged ED to depression and anxiety symptoms. Comparisons between admission and discharge networks indicated the global network strength did not change significantly, though symptom severity decreased. Participants with denser networks at admission evidenced less change in ED symptomatology during treatment. Findings suggest that symptoms related to shape and weight concerns and guilt are central ED symptoms, while physical symptoms, self-esteem, and feeling overwhelmed are links that may underlie comorbidities in EDs. Results provided some support for the validity of network approaches, in that admission networks conveyed prognostic information. However, the lack of correspondence between symptom reduction and change in network strength indicates that future research is needed to examine network dynamics in the context of intervention and relapse prevention.

S202. EFFICACY OF LONG-TERM RESIDENTIAL TREATMENT FOR PERSISTENT MENTAL ILLNESS

BackgroundIn the United States, the number of public and private psychiatric hospital beds has steadily declined in recent years, despite the lack of intensive intermediate care alternatives in the community. The design and implementation of intensive residential treatment programs are not currently guided by controlled studies, but these studies are necessary to determine the clinical and economic utility of such programs. We present clinical and outcome data on an initial sample of patients treated over the last 5 years.MethodsNaturalistic, non-controlled assessment of symptomatic and functional outcome in an initial sample of young adults with persistent mental illnesses treated in a community-based residential program. Patients were treated with an individualized combination of modalities such as Illness Education and Management, Supported Employment, Individual, Group and Family Psychotherapies and Psychopharmacology. Standard clinical rating scales were used during the period of treatment and all discharged patients were contacted on an annual basis in order to complete a survey of clinical outcome.Results101 patients had been admitted and treated since the facility opened in October 2011. Median age of the patients was 25 years, mean illness duration was 12.6 years, and the mean number of prior hospitalizations was 6.5. Diagnostic distribution was: 36.7% psychotic disorders, 27.7% unipolar mood disorders, 19.8% bipolar mood disorders, 7.9% autism spectrum disorders, and 7.9% post-traumatic stress disorder or other anxiety conditions. 37% of residents met criteria for personality disorders, the majority of which was borderline personality disorder. 42% of residents also met criteria for a substance use disorder in the year prior to admission. Ratings on the Multnomah Community Ability Scale improved by 16%, ratings on the Brief Psychiatric Rating Scale declined by 20% and ratings on the Montgomery-Asberg Depression Rating Scale declined by 37%. The average survey response rate after discharge was 59%. With regard to community engagement: 40.3% of current residents and 35.1% of discharged residents were competitively employed. 16.7% of current residents and 17.8% of discharged residents worked as volunteers, and 23.3% of current residents and 26.3% of discharged residents were attending school. A survey of dispositions revealed that: 49.7% of discharged residents were living independently, 14.9% were living with family, 2.2% were homeless, and 5.4% had died from suicide. The hospitalization rate declined from 0.84/year to 0.57/year before and after discharge.DiscussionLong-term residential treatment for young adults with persistent mental illness results in improved symptomatic recovery, independent living, increased employment rates, and reduced hospitalizations.

Relationships Between Treatment Delivery, Program Attrition, and Reoffending Outcomes in an Intensive Custodial Sex Offender Program.

Retention of sex offenders to the completion of treatment is critical to program adherence to risk need responsivity (RNR) principles; however, it is also important to consider the potential interaction between attrition and treatment outcomes such as reoffending. The first aim of this study was to evaluate the influence of changes to treatment delivery in a residential sex offender treatment program (SOTP), including introduction of rolling groups and systematic emphasis on positive therapist characteristics, on likelihood of program noncompletion ( n = 652). Pooled regression modeling indicated that these operational interventions were associated with a significantly increased likelihood of program completion. We also examined whether variance in rates of participant attrition was related to reoffending outcomes for program completers ( n = 494). Incidence of attrition within completing participants' treatment cohorts had a significant negative association with hazard of sexual reoffending that was not accounted for by pretreatment risk. Results are discussed in terms of their implications for treatment delivery processes that aim to optimize both participant retention and treatment effectiveness.

How centers handle young patients who want to leave AMA

Residential treatment programs treating substance use disorders are not locked from the inside — for young adults and adolescents, as well as for adults. But when they want to leave against medical advice (AMA), what is the solution? Residential programs are not psychiatric facilities where people are locked in when they are deemed harmful to themselves (suicidal) or others. That said, parents with minor children — and parents of young adult children — want to know that their child is safe. They don't want to hear that their child has run away. We talked to two large programs about the best ways to handle young people who want to leave.

VA residential treatment providers' use of two evidence-based psychotherapies for PTSD: Global endorsement versus specific components.

Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT). Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT. Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment. These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record

Examining Insomnia and PTSD Over Time in Veterans in Residential Treatment for Substance Use Disorders and PTSD

ABSTRACT Objective/Background: Insomnia occurs in 66–90% of individuals with posttraumatic stress disorder (PTSD) and 36–72% of individuals with substance use disorder (SUD). Individuals with both PTSD and SUD are more likely to have insomnia than individuals with only one disorder. Insomnia is associated with poorer treatment outcomes for both PTSD and SUD, increased daytime symptomology for PTSD, and increased relapse for SUDs. As such, it is important to understand how sleep affects PTSD treatment among patients dually diagnosed with SUD and how sleep changes over time in a residential unit for SUDs. Participants: Participants were 40 veterans with comorbid PTSD and SUD in a 28-day Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) PTSD track. Methods: Analyses used mixed models with Time (baseline, posttreatment, 3-month follow-up) to examine PTSD and insomnia severity over time. Results: Results of the longitudinal mixed model showed that PTSD symptoms improved over time but that insomnia symptoms did not. Although baseline insomnia did not affect follow-up PTSD symptoms, individuals with greater insomnia severity at the start of treatment had more severe baseline PTSD symptomatology. However, there was not an interaction of insomnia and PTSD severity over time such that baseline insomnia did not affect PTSD trajectories. Conclusions: These findings are consistent with the PTSD outpatient treatment findings and further adds evidence that insomnia is unremitting without direct intervention. Given the relationship insomnia has with PTSD severity, SUD, and relapse, directly targeting insomnia may further help improve both PTSD and SUD treatment outcomes.

Implementation of Dialectical Behavior Therapy in Residential Treatment Programs: A Process Evaluation Model for a Community-Based Agency.

Dialectical behavior therapy (DBT) can be challenging to implement in community-based settings. Little guidance is available on models to evaluate the effectiveness or sustainability of training and implementation efforts. Residential programs have much to gain from introduction of evidence-based practices, but present their own challenges in implementation. This paper presents a low-cost process evaluation model to assess DBT training piloted in residential programs. The model targets staff and organizational factors associated with successful implementation of evidence-based practices and matches data collection to the four stages of the DBT training model. The strengths and limitations of the evaluation model are discussed.

Changes in Neuropsychological Status during the Initial Phase of Abstinence in Alcohol Use Disorder: Neurocognitive Impairment and Implications for Clinical Care

ABSTRACTBackground: Neuropsychological deficits are common in individuals with alcohol use disorder (AUD) and impact daily functioning and AUD treatment outcomes. Longitudinal studies demonstrate that extended abstinence improves neuropsychological functioning. The effects of short-term abstinence are less clear. Objectives: This study examined changes in neuropsychological functioning after acute detoxification over a 10-day period at the beginning of residential AUD treatment. Notably, this study evaluated cognitive functioning according to diagnostic classifications for neurocognitive disorder according to DSM-5. Methods: Using a within-subjects design, neuropsychological functioning of participants (N = 28) undergoing a 14-day residential AUD treatment program was assessed at two time points over 10 days (i.e., treatment entry, prior to treatment discharge). Tests of immediate memory, visuospatial abilities, attention, language abilities, delayed memory, and executive functioning were administered. Results: After completing acute detoxification, almost all participants (93%) were clinically impaired in at least one of the five cognitive domains at residential treatment entry, with one third of the sample impaired on ≥3 domains. Ten days later, 71% remained clinically impaired in at least one of five cognitive domains, with 29% of the sample impaired on ≥3 domains. Significant improvement over the 10-day period was observed for immediate memory, visuospatial abilities, and overall cognitive functioning. Clinical significance of these changes is also reported. Conclusions/Importance: The results from this study help to characterize cognitive functioning in terms of neurocognitive impairment. A brief period of abstinence begins to ameliorate neuropsychological deficits, but many individuals remain cognitively impaired throughout treatment. Implications for treatment are discussed.

Dissociative symptoms mediate the relation between PTSD symptoms and functional impairment in a sample of military members, veterans, and first responders with PTSD

ABSTRACTBackground: Posttraumatic Stress Disorder (PTSD) is associated with significant functional impairment in important areas, including interpersonal relationships and occupational or educational roles. Preliminary evidence suggests that the dissociative subtype of PTSD (PTSD+DS), characterized by marked symptoms of depersonalization and derealization, is associated with increased functional impairment and disease severity, including among military members and veterans diagnosed with PTSD. Similarly, first responders (e.g. police, fire, paramedics) have also been found to experience dissociative symptoms. Despite these findings, little work has investigated whether dissociative symptoms are related to heightened functional impairment among these populations.Objective: We examined the relation between functional impairment and symptom level variables, including dissociative symptoms of depersonalization and derealization among military members, veterans, and first responders with probable PTSD. We further investigated the hypothesis that dissociative symptoms mediate the relation between PTSD symptomatology and functional impairment.Method: Eighty-one medical charts of inpatients at a residential PTSD treatment programme were accessed via retrospective review. Sixty-two were included in the present analyses. Comparison of means on symptom measures between first responders and military members/veterans were conducted, followed by correlational and mediation analyses.Results: Compared with first responders, military members and veterans showed higher levels of derealization, functional impairment, alexithymia, anxiety, and depression. Within the total sample, dissociative symptoms emerged as the strongest correlate of functional impairment and, among the dissociative symptom clusters, derealization symptoms demonstrated the strongest relation with impairment. Mediation analyses revealed that total dissociative symptoms and derealization symptoms significantly mediated the relation between PTSD symptoms and functional impairment.Conclusions: These findings highlight the importance of assessing and treating dissociative symptoms, consistent with the dissociative subtype of PTSD, among military members, veterans, and first responders with PTSD. Successful recovery on a functional and symptomatic level may necessitate treatment of dissociative symptoms, particularly derealization.

Veterans in substance abuse treatment program self-initiate box gardening as a stress reducing therapeutic modality

ObjectivesTo assess the experiences of a veteran initiated horticultural therapy garden during their 28-day inpatient Substance Abuse Residential Rehabilitation Treatment Program (SARRTP). DesignRetrospective study. SettingVeterans Affairs Medical Center (VAMC), Salem, Virginia, USA InterventionsGroup interviews with veterans from the last SARRTP classes and individual interviews with VAMC greenhouse staff in summer of 2016. Outcome measuresTime spent in garden, frequency of garden visits, types of passive and active garden activities, words describing the veterans’ emotional reactions to utilizing the garden. ResultsIn 3 summer months of 2016, 50 percent of the 56 veterans interviewed visited and interacted with the gardens during their free time. Frequency of visits generally varied from 3 times weekly to 1–2 times a day. Amount of time in the garden varied from 10min to 2h. The veterans engaged in active and/or passive gardening activities during their garden visits. The veterans reported feeling “calm”, “serene”, and “refreshed” during garden visitation and after leaving the garden. ConclusionsAlthough data was secured only at the end of the 2016 growing season, interviews of the inpatient veterans revealed that they used their own initiative and resources to continue the horticulture therapy program for 2 successive growing years after the original pilot project ended in 2014. These non-interventionist, therapeutic garden projects suggest the role of autonomy and patient initiative in recovery programs for veterans attending VAMC treatment programs and they also suggest the value of horticulture therapy as a meaningful evidence- based therapeutic modality for veterans.

Randomized Controlled Trial Comparing Exercise to Health Education for Stimulant Use Disorder: Results From the CTN-0037 STimulant Reduction Intervention Using Dosed Exercise (STRIDE) Study.

To evaluate exercise as a treatment for stimulant use disorders. The STimulant Reduction Intervention using Dosed Exercise (STRIDE) study was a randomized clinical trial conducted in 9 residential addiction treatment programs across the United States from July 2010 to February 2013. Of 497 adults referred to the study, 302 met all eligibility criteria, including DSM-IV criteria for stimulant abuse and/or dependence, and were randomized to either a dosed exercise intervention (Exercise) or a health education intervention (Health Education) control, both augmenting treatment as usual and conducted thrice weekly for 12 weeks. The primary outcome of percent stimulant abstinent days during study weeks 4 to 12 was estimated using a novel algorithm adjustment incorporating self-reported Timeline Followback (TLFB) stimulant use and urine drug screen (UDS) data. Mean percent of abstinent days based on TLFB was 90.8% (SD = 16.4%) for Exercise and 91.6% (SD = 14.7%) for Health Education participants. Percent of abstinent days using the eliminate contradiction (ELCON) algorithm was 75.6% (SD = 27.4%) for Exercise and 77.3% (SD = 25.1%) for Health Education. The primary intent-to-treat analysis, using a mixed model controlling for site and the ELCON algorithm, produced no treatment effect (P = .60). In post hoc analyses controlling for treatment adherence and baseline stimulant use, Exercise participants had a 4.8% higher abstinence rate (78.7%) compared to Health Education participants (73.9%) (P = .03, number needed to treat = 7.2). The primary analysis indicated no significant difference between exercise and health education. Adjustment for intervention adherence showed modestly but significantly higher percent of abstinent days in the exercise group, suggesting that exercise may improve outcomes for stimulant users who have better adherence to an exercise dose. ClinicalTrials.gov identifier: NCT01141608.

Oxytocin Genotype Moderates the Impact of Social Support on Psychiatric Distress in Alcohol-Dependent Patients.

The social environment strongly influences individual mental health. Individuals with strong social support systems tend to experience higher levels of well-being, lower levels of psychological distress and exhibit fewer psychiatric symptoms. However, there is a significant degree of individual variability as to the extent to which social support is beneficial to overall mental health. From a neurobiological perspective, it is suggested that the social hormone, oxytocin, may moderate the favorable effects of social interaction. To explore this possibility, we evaluated oxytocin genotype, social support and psychological health in a group of individuals diagnosed with DSM-IV alcohol dependence. The associations between OXT genotype, social support and psychological health were analyzed in data from 269 adults diagnosed with DSM-IV alcohol dependence (25% female) admitted into residential treatment programs and outpatient centers in Warsaw, Poland. In line with past observations, we noted that psychiatric distress scores were negatively correlated with social support. Extending these observations, we uncovered a significant moderating effect of OXT genotype (rs2740210) on the relationship between social support and psychiatric distress. While G carriers displayed the predicted negative relationship between social support and psychiatric distress, T homozygotes failed to exhibit such a relationship. Genetically driven variation in oxytocin system functioning may influence the degree to which the beneficial effects of social support are felt in this population. These results have direct clinical relevance as enhancing social engagement to improve mental health may prove to be a less effective strategy in some patients owing to intrinsic factors. The associations between oxytocin genotype, social support, and psychological health were analyzed in data from 269 adults diagnosed with DSM-IV alcohol dependence. A significant moderating effect of OXT genotype (rs2740210) on the relationship between social support and psychiatric distress was detected.

Dissociative and complex trauma disorders in health and mental health contexts: Or why is the elephant not in the room?

I went looking for a residential treatment program the other day. One of my clients having received a dual diagnosis—alcohol abuse and dissociative identity disorder. In Southern Calfornia, where I...

Multimodal Residential Treatment for Adolescent Anxiety: Outcome and Associations with Pre-treatment Variables

This study aimed to determine the effect of a multimodal residential treatment program for severe adolescent anxiety, and examine whether treatment outcome was associated with pre-treatment anxiety, comorbid disorders, or participant age or gender. Participants were 70 adolescents (61.4% female, mean age = 15.4years) with a primary anxiety disorder who received residential treatment involving cognitive behavioral therapy and medication management. Treatment outcome was assessed both as the change in adolescent-reported anxiety symptoms, and using treatment response criteria. Results indicated a strong effect of the intervention on symptoms of anxiety, depression, and anxiety-related life interference. Most pre-treatment variables were not associated with treatment outcome. However, higher adolescent-reported pre-treatment anxiety was associated with a greater reduction in anxiety at post-treatment, and the presence of a comorbid anxiety disorder was associated with poorer odds of treatment response. Findings indicate that residential treatment is a robust intervention for adolescent anxiety.

9.4 Family Connections: A Program for Adolescents and Parents

Research suggests that a lack of understanding/information on borderline personality disorder (BPD), parents' own emotion about their children's difficulties, and a lack of parent and relationship skills for dealing with their troubled teenagers may contribute to poorer outcomes for both teenagers with BPD-related problems and their parents. Family Connections (FC) is a free 12-week program designed to address three areas of potential deficits: 1) education on BPD, emotion dysregulation, and family interactions; 2) individual skills to help parents cope; and 3) relationship and parent skills to help parents interact with their teenagers in healthier ways. FC (a group program) also provides parents peer support. Prior studies show reductions in burden, depression, and grief and an increase in empowerment with sample groups consisting of parents of teenagers, parents of adults, partners, and siblings. Data from the present study evaluate FC impact on suicidal and self-harming teenagers in a residential treatment program.

Aikido as an Augment to Residential Posttraumatic Stress Disorder Treatment

There is strong evidence to support the effectiveness of residential PTSD treatment programs among military veterans; however, efforts are needed to build upon the effectiveness of these programs to improve patient outcomes. The present study examined the effects of augmenting an evidenced-based residential PTSD treatment program for veterans with group-based instruction in Aikido. Aikido is a nonpercussive martial art (no board breaking) focusing on empowering practitioners to neutralize aggression and defend oneself without hurting others. A quasi-experimental design was used to test for between-groups differences (receiving Aikido vs. not receiving Aikido) on PTSD and depression symptom change in a sample of male (n = 108) and female (n = 85) residential PTSD patients. Results suggest that female veterans receiving Aikido experienced a greater decrease in self-reported symptoms of PTSD (partial η2 = .05) and depression (partial η2 = .05) while in residential treatment. Significant benefits were not found for male veterans receiving Aikido. These findings support Aikido as a viable augment to evidence-based residential PTSD treatment for veterans, particularly for female veterans with comorbid symptoms of depression.

Prevalence and motivations for kratom use in a sample of substance users enrolled in a residential treatment program

BackgroundKratom use in the West has increased recently, yet the prevalence and motives for use among individuals with a history of substance use disorder (SUD) have not been fully examined. Kratom has been documented as a means of treating chronic pain, mitigating drug dependence, and easing withdrawal symptoms, yet it is unclear if substance users are utilizing kratom as a self-medication. Abuse liability, side effects, and overall appeal of kratom remain uncertain. MethodsIn April 2017, an anonymous survey regarding kratom use and motivations was completed by clients enrolled in a 12-Step-oriented residential program. 500 respondents with a self-reported history of SUD completed the survey. Results20.8% of respondents endorsed lifetime kratom use and 10.2% reported past-12-month use. Kratom-users were younger (=32.1 vs. 35.9, p<0.001) and were more versatile substance users. A majority (68.9%) of kratom-users reported having used the drug as a means of reducing or abstaining from non-prescription opioids (NPO) and/or heroin, and 64.1% reported using kratom as a substitute for NPO/heroin. 18.4% of kratom-users reported using the drug due to a disability or chronic pain. One-third of kratom-users stated that kratom was a helpful substance and that they would try it again. However, kratom was not preferred and was indicated as having less appeal than NPO, heroin, amphetamines, and Suboxone. ConclusionsAmong substance users, kratom use may be initiated for a variety of reasons, including as a novel form of harm-reduction or drug substitution, particularly in the context of dependence and withdrawal from other substances.

Process factors explaining psycho-social outcomes in adventure therapy.

The development and factor analysis of the Adventure Therapy Experience Scale (ATES) is the first attempt found in the literature to empirically and quantitatively identify therapeutic factors theorized to affect change in the adventure therapy experience (Russell & Gillis, 2017). This study utilizes the ATES to explore how its inherent factors may impact treatment outcome utilizing a routine outcome monitoring process to empirically test how these factors may contribute to treatment outcome over time. The sample of 168 males 21.5 years of age completed an average of 79.6 days in the 90-day adventure-based substance use disorder residential treatment program. In the model, adventure-based experiences are a primary treatment tool. For outcome monitoring, all clients were administered the Outcome Questionnaire (OQ-45.2) at intake, every 2 weeks, and at discharge. In addition, clients were administered the 18-item ATES every 2 weeks. The ATES contains 2 items measuring how helpful the adventure experience was as well as how mindful they were of their treatment process during the experience. Clients also answer 16 Likert items measuring responses on 4 subscales: group adventure, nature, challenge, and reflection. Results reveal that clients, on average, improved in their psycho-social functioning as measured by the OQ 45.2. Weeks with higher helpfulness, mindfulness, and group adventure scores than the client's average helpfulness, mindfulness, and group adventure score, had greater decreases in OQ scores than weeks with lower helpfulness, mindfulness, and group adventure scores. Clients with higher aggregate helpfulness and group adventure scores, across all treatment weeks, had greater decreases in OQ scores than clients with lower aggregate helpfulness and group adventure scores. Implications for practice and future research are also discussed. (PsycINFO Database Record

Understanding interactions of formerly incarcerated HIV-positive men and transgender women with substance use treatment, medical, and criminal justice systems

BackgroundLow levels of medical care engagement have been noted for HIV-positive people leaving systems of incarceration in the United States. Substance misuse frequently co-occurs with criminal justice involvement in individuals who are living with HIV. MethodsWe analyzed data from in-depth interviews with 19 HIV-positive individuals who were currently or formerly incarcerated in order to elucidate challenges faced in accessing care and maintaining HIV treatment regimens when cycling out of (and often back into) custody. Our thematic analysis used an ecosocial framework to describe participants’ shifts between substance use treatment, medical care, and criminal justice systems. ResultsDominant themes included the dramatic increase in HIV-treatment-related autonomy required following release from jail because of differences in care delivery between custody-based and community-based care systems; the important, but temporary stabilization provided by residential substance use treatment programmes; and the inconsistency of substance use treatment approaches with chronic care models of disease management. ConclusionEnhanced integration of criminal justice, medical care, and substance use treatment institutions in planning for reentry of HIV populations may ease the impact of the dramatic shifts in context that often dissuade linkage and retention. This integration should include coordination with custody release processes, periodic assessments for active substance misuse in HIV treatment settings, support for (re)establishing health-promoting social networks, and options for long-term, residential substance use treatment programmes.