Residential Treatment Program Research Articles

Adjudicated Adolescents Located on a State Sex Offender Registry Website as Adults: Common Denominators

ABSTRACT This is a landmark study, the first to use a listing on a state sex offender registry website as a predictive variable for tracking adult recidivism of male adolescents adjudicated for sex offenses, and the longest to follow a cohort of these youth after discharge from a secure residential treatment program. Upon admission, the sample (N = 145) were assessed by JSORRAT-II and MEGA ♪ , two contemporary standardized, validated risk assessment tools for assessing youth who have engaged in sexually abusive behavior. They were then followed once discharged for 17.08 years into adulthood (mean follow-up = 14.0 years, SD = 1.71). Recidivism rate was 6.2% (defined as a listing for the subject on the California Megan’s Law Sex Offender Registry Website). The study offers a baseline for future studies that use a state sex offender registry website as a predictive variable for recidivism. Shared common denominators of recidivists and non-recidivists were risk level (i.e. most were High Risk or Very High Risk on MEGA ♪ ); and having a history of adverse childhood experiences other than sexual abuse (i.e. child neglect/emotional abuse and exposure to domestic violence). A history of sexual abuse, experienced by twice as many non-recidivists as recidivists, differentiated the sample. Recidivists also had fewer protective factors than non-recidivists, as assessed by the MEGA ♪ upon admission to the facility. The mean age of recidivists was younger than non-recidivists, suggesting they may have been removed from their home at an early age, and/or had an early onset of persistent coarse sexual improprieties and/or sexually abusive behaviors that persisted into adulthood. The results highlight the importance of integrating trauma-informed interventions in treatment programs for those individuals who are sexually abusive that have a history of multiple adverse childhood experiences.

3 Neuropsychiatric Change and Childhood Adversity Levels in an Opioid Treatment Population

Objective:Early life adversity is strongly correlated with a number of negative health outcomes, with some of the highest risks are related to later illicit drug use and substance use disorders (SUDs). Specifically, it has been found that an ACEs score of >4 confers a 7-10-fold risk of substance abuse. Subsequent research has identified a number of neurobiological effects of childhood trauma, including structural and functional disruptions of the LHPA axis, the brain's primary stress-response system. It has been hypothesized that various trauma-induced neurobiological changes may lead to later physical health, mental health, and psychosocial problems in persons with early life adversity. One area that such changes might affect is a person's ability to stop abusing substances, with factors such as trauma-related mood, self-efficacy, or cognitive functioning as considerations in early treatment success. This study followed a group of participants in a residential substance abuse treatment program across their first month of abstinence, to assess natural change in cognitive performance as well as potential effect of early life adversity on changes in neuropsychiatric outcomes.Participants and Methods:Participants were 37 adults (mean age=33.9 years, SD=6.7) who had completed detoxification and were first assessed during their first week of residential treatment. Follow-up assessment was completed 4 weeks later. Participants were primarily male (62%) and white (62%). They were all in treatment for opioid abuse, with a majority of participants reporting a history of polysubstance abuse. To measure adverse and protective factors, participants completed the Adverse Childhood Experiences scale and Protective And Compensatory Experiences Scale at baseline. Participants also completed the NIH Toolbox cognition battery and a set of self-report measures of cognitive functioning, mood, anxiety, and self-efficacy at baseline and follow up.Results:Results of paired samples t-test comparison between baseline and follow-up testing found a significant improvement in self-reported depression symptoms, anxiety symptoms, and self-efficacy (all p<.001). Interestingly, participants overall reported an increase in cognitive problems between baseline and retest, even though on objective cognitive testing (NIH Toolbox cognition battery) there was significant improvement in cognitive performance. Participants generally had a high level of childhood adversity (mean ACE score of 4.5), with an average level of childhood compensatory experiences. Considering the specific effect for childhood adversity, ACE score was found to be predictive in amount of anxiety and self-reported cognitive change but not for objective cognitive performance or change in other factors.Conclusions:Consistent with previous research, these patients had a high level of past trauma, which interacted with a number of other neuropsychiatric measures and support the importance of assessing for trauma history and integrating trauma-focused treatment into substance abuse treatment programs.

"I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment.

Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Clinical outcomes of veterans affairs residential PTSD treatment for PTSD and depressive symptoms: 1-year follow-up outcomes and gender differences.

The long-term effectiveness of Department of Veterans Affairs (VA) residential treatment for posttraumatic stress disorder (PTSD), and how it may vary for men and women veterans, is unknown. This is the first national investigation of symptom change from admission, discharge, 4 months, and 1-year postdischarge from VA PTSD residential rehabilitation treatment programs (RRTPs). Participants included all veterans discharged from 40 VA PTSD RRTPs October 1, 2017-September 30, 2020 (n = 2,937; 14.3% women). Linear mixed models examined PTSD and depressive symptoms across time points; it was hypothesized that women veterans would experience greater symptom reduction during and after treatment. Overall, veterans reported large-sized reductions of PTSD symptoms at all time points (Cohen's d: discharge = 1.23, 4-month follow-up d = 0.97, 1-year follow-up d = 1.51). Treatment effects for depressive symptoms were large-sized at all time points (Cohen's d; discharge = 1.03, 4-month follow-up d = 0.94, 1-year follow-up d = 1.05). Women veterans showed greater improvement in PTSD and depressive symptom severity (p < .001) than men at discharge, but not at 4-month or 1-year follow-ups. Veterans reported significant reductions in PTSD and depressive symptoms, and treatment gains were maintained one year postdischarge. Women experienced greater benefit during, but not after, treatment. Results not only provide support for the effectiveness of VA residential treatment for PTSD but also highlight the continued need for strategies to maximize and maintain treatment gains. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Physiology of human-horse interactions during substance withdrawal within psychotherapy participants

Abstract Psychotherapy incorporating equine interaction (PIE) is emerging as an effective treatment for substance use disorder (SUD); however, research concerning physiological impacts of PIE during substance withdrawal is lacking. This study investigated impacts of PIE on salivary cortisol concentrations and heart rates in SUD patients during withdrawal. Heart rate and cortisol concentrations were also measured in horses to investigate potential human-horse coupling during PIE. Saliva samples and heart rates were collected from SUD patients (n = 18) and their therapy horses (n = 4) prior to the introduction of the horse and following equine interaction within a residential psychotherapy program during the substance withdrawal period. Without the presence of the horse, the equine environment during the first week of withdrawal produced lower () cortisol and heart rate measures than found in the equine interaction for the SUD patients. Human heart rates, however, decreased () in the second week in response to the equine interaction. A strong negative correlation (r = −0.9, ) was found within the changes in human and horse cortisol concentrations during week two as human cortisol concentrations decreased while horse cortisol concentrations increased. Results indicate equine interaction during psychotherapy is more effective in the second week than the first at mitigating stress for withdrawing residential SUD treatment program patients and the equid environment, even without the presence of a horse, can positively impact stress parameters in withdrawing SUD patients during the first week of treatment.

A case study on variations in network structure and cross-sector alignment in two local systems serving pregnant and parenting women in recovery.

To describe network structure and alignment across organizations in healthcare, public health, and social services sectors that serve pregnant and parenting women with substance use disorder (SUD) in an urban and a rural community. Two community networks, one urban and one rural with each including a residential substance use treatment program, in Kentucky during 2021. Social network analysis measured system collaboration and cross-sector alignment between healthcare, public health, and social services organizations, applying the Framework for Aligning Sectors. To understand the alignment and structure of each network, we measured network density overall and between sectors, network centralization, and each organization's degree centrality and effective size. Computer-assisted telephone interviews were conducted to document alignment around shared purpose, data, financing, and governance. On average, overall and cross-sector network densities in both communities were similar. However, alignment was highest for data sharing and financing in the urban community and for shared purpose and governance in the rural community. Cross-sector partnerships involving healthcare organizations were more prevalent in the rural county (44% vs. 38% for healthcare/public health, 44% vs. 29% for healthcare/social services), but more prevalent for those involving public health/social services organizations in the urban county (42% vs. 24%). A single healthcare organization had the highest degree centrality (Mdn [IQR] = 26 [26-9.5]) and effective size (Mdn [IQR] = 15.9 [20.6-8.7]) within the rural county. Social services organizations held more central positions in the urban county (degree centrality Mdn [IQR] = 13 [14.8-9.5]; effective size Mdn [IQR] = 10.4 [11.4-7.9]). Cross-sector alignment may strengthen local capacity for comprehensive SUD care for pregnant and parenting women. Healthcare organizations are key players in cross-sector partnerships in the rural community, where one healthcare facility holds the central brokerage role. In contrast, public health agencies are key to cross-sector collaboration with social services in the urban community.

A qualitative study on the implementation of a transdiagnostic cognitive behavioral therapy for children in a child welfare residential treatment program

BackgroundYouth with severe emotional or behavioral issues who are involved with child welfare authorities are sometimes placed in intensive care services in a residential treatment program. Evidence-based psychotherapies are often used in residential treatments, but there is very little research on how to adapt psychotherapy for residential treatment. ObjectiveTo describe the implementation of a transdiagnostic cognitive behavioral therapy (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children) in a residential treatment program for children. Participants and settingStaff (n = 20) at a residential facility in Calgary, Canada. MethodsA combination of qualitative interviews and focus groups were conducted before and after therapy to identify barriers and facilitators to implementation. Data were analyzed and reported using the Consolidated Framework for Implementation Research and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies. ResultsModifications were made to the program including creating inclusive language, integrating relevant content targeting pediatric irritability, delivering sessions online for caregivers, and using additional staff to support youth to learn and practice the application of the content and behavioral interventions. Key barriers to implementation of the Unified Protocol included staff turnover and the difficulty of sustaining a critical mass of knowledge surrounding the Unified Protocol. The major facilitators to implementation were the perceived quality of the program and advantages of the program to children and their caregivers. ConclusionsThis study supports the feasibility and acceptability of providing transdiagnostic cognitive behavioral therapies for children in residential treatment and provides a template for how to implement evidence-based practice in residential treatment.

Psychotherapy Incorporating Equine Interaction as a Complementary Therapeutic Intervention for Young Adults in a Residential Treatment Program during the COVID-19 Pandemic

Substance use disorder has become an epidemic in the young adult population across the United States, and these numbers rose during the COVID-19 pandemic. Psychotherapy incorporating equine interaction has emerged to show promise in the mental health community as a complementary form of therapy for this age group and offered a viable treatment option during the pandemic due to the outdoor nature of the treatment environment. However, research concerning its use within a residential treatment program was lacking. The objective of this study was to evaluate the efficacy of psychotherapy incorporating equine interaction in a residential treatment program during the COVID-19 pandemic for developing an emotionally safe environment for learning for young adults. Participants (ages 18–25 years) were those in a substance abuse residential treatment program utilizing psychotherapy incorporating equine interaction during the COVID-19 pandemic. Participants were involved in weekly equine therapy for 2–7 weeks. Participants were divided according to length of stay at the residential facility and participation level with equine interactive activities. Assessment of emotional safety and long-term memory development was performed at the beginning and end of the treatment program. The development of memories centered around equine information that was covered during the treatment program. Semantic memory was assessed using a self-reporting knowledge exam and procedural memory was assessed using a skill evaluation. Emotional safety was determined using a self-reporting survey instrument. Paired t-tests determined significant improvement in emotional safety (p = 0.02) and semantic (p = 0.01) and procedural (p = 0.00) memory for all participants by the end of the program. The one-way analysis of variance indicated length of stay and participation level were not significant indicators of emotional safety (length of stay: p = 0.91, participation level: p = 0.98) and semantic (length of stay: p = 0.09, participation level: p = 0.60) and procedural (length of stay: p = 0.25, participation level: p = 0.09) memory development. These results suggest psychotherapy incorporating equine interaction was an efficient complementary therapeutic intervention for developing emotional safety and encouraging learning in a young-adult residential addiction treatment program during the COVID-19 pandemic.

Tai Chi as a Complementary Therapy for Depression and Anxiety Among U.S. Veterans in a Mental Health Inpatient Setting.

Depression and anxiety are two of the top five mental illnesses veterans report. Treatment for depression and anxiety includes medications and psychiatric treatment in inpatient, outpatient, and residential treatment programs; the use of complementary and alternative medicine (CAM) can have beneficial results by decreasing symptoms, recognize patients' preference for CAM, and be cost-effective. This study aimed to evaluate the effects of Tai Chi on depression and anxiety symptoms on inpatient psychosocial or substance use disorder (SUD) rehabilitation treatment program residents since little evidence exists regarding the effectiveness of Tai Chi on participants in residential mental health treatment programs. METHOD: A mixed-method, cohort design with 88 participants (41 usual treatment without Tai Chi, 47 intervention) used a demographic survey, Hamilton Anxiety Scale, Quick Inventory of Depressive Symptomatology, self-report, and the Patient Health Questionnaire-9 at Weeks 1 and 4 of the treatment program. After Week 4, the intervention group responded to six open-ended questions about Tai Chi's effects on their overall depression and anxiety. The anxiety level of the intervention group was significantly decreased, as evidenced by the Hamilton Anxiety Scale scores (p = .02). However, the measures of depression did not differ between the groups. Two themes, mindfulness and satisfaction, were identified from the written responses regarding the Tai Chi intervention. Tai Chi effectively reduced symptoms of anxiety that varied by age and ethnicity. This study increased the insight regarding the benefit of including Tai Chi as a complementary therapy for those participating in residential treatment programs.

Examining the Use of Career Development Curricula in Adolescent Residential Treatment Programs

Research suggests adolescents leaving residential treatment programs have higher levels of unemployment and homelessness than average. This exploratory study examined what types of career development curricula are being used in residential treatment programs. The findings suggest that most residential treatment programs use little to no career development curriculum. The long-term goal is to support the critical need and development of a specialized career development curriculum for adolescents residing in residential group home programs.

Characteristics of a Southern Intensive Trauma- and Psychiatric-Focused Recovery Program.

Treatment of substance use disorders (SUDs) is complex, involving biological, psychological, and social factors to be considered when designing effective programs. Trauma-informed psychiatric care integrated with a developmentally appropriate intensive 12-step approach is being used at A Reprieve for Women (Reprieve), a long-term intensive residential recovery program for female emerging adults with SUDs located in Tuscaloosa, Alabama. The Reprieve treatment philosophy focuses on long-term intensive care, treatment of coexisting trauma and psychiatric disorders, and development of life skills. The purpose of this article is to outline Reprieve's programmatic features and report Reprieve's 1- and 2-year sobriety rates for women who completed the 6-month residential program and compare it with national sobriety rates for other residential SUD treatment programs. Reprieve provided 1- and 2-year sobriety rates and duration of treatment from 110 deidentified participants who completed Reprieve's 6-month residential program between September 2016 and November 2020. The researchers defined sobriety as complete abstinence from any addictive substances. Reprieve staff contacted program graduates to determine sobriety status following completion of the program. This research, approved by the University of Alabama's institutional review board, involved usable data points from 68 of the 110 participants. We determined that Reprieve has a 75% 1-year sobriety rate and a 63% 2-year sobriety rate. The national average sobriety rate for people completing SUD treatment in residential programs is 40%. Reprieve's higher-than-national sobriety rates make it a valuable program to study. Its emphasis on the treatment of coexisting psychiatric problems and past traumas, development of life skills, and the unique needs of female emerging adults may contribute to the program's success. It is hoped that this program description and preliminary analysis of outcomes will provide valuable information for future SUD treatment program development. More rigorous study is needed to delineate the effects of specific programmatic features on sobriety.

Pilot randomized controlled trial of a brief strategy to prevent suicide after discharge from residential addiction treatment

IntroductionVeterans are at greater risk for suicide and veterans with substance use disorder (SUD) have an even greater risk. Little research has looked into brief interventions to prevent suicide in this population in residential substance use treatment programs. MethodWe conducted a pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients participating in the Residential Recovery Center (RRC) SUD 28-day program and deemed at risk for suicide. We measured changes in symptoms at 1-, 3-, and 6-months. We looked at social connectedness, suicidal ideation, hopelessness, thwarted belongingness, perceived burdensomeness, and treatment engagement. ResultsThe study enrolled twenty patients. One participant withdrew immediately after baseline. We found that adherence to VA BIC components was high, as 100 % of patients (N = 10) completed 70 % or more of the VA BIC visits. Furthermore, 80 % of intervention group patients (N = 8) completed all VA BIC components. During the six-month follow-up, suicidal ideation improved in patients assigned to VA BIC, while it worsened in the standard care arm. Similarly, patients assigned to VA BIC reported a reduction in perceived burdensomeness over the six-month follow-up period while it worsened in the standard care arm. Additionally, VA BIC may modestly improve treatment engagement in the first month postdischarge. ConclusionWe were able to recruit and enroll patients from a residential SUD treatment program into a clinical trial of the VA BIC intervention. Our preliminary results suggest that VA BIC may be useful in reducing suicidal ideation and perceived burdensomeness in patients who are discharged from residential SUD treatment programs and increasing treatment engagement. Future trials of VA BIC should determine whether VA BIC can reduce the risk of suicide in patients who are discharged from residential SUD treatment programs.

Gambling, tobacco use, and health among individuals in substance use disorder treatment.

Gambling is highly comorbid with disordered use of tobacco and other drugs, and may increase relapse risk among substance use disorder (SUD) patients. We investigated associations between gambling and tobacco use behaviors among SUD patients to inform clinical care. Patients (N = 651, 170 female) from 25 residential SUD treatment programs in California completed surveys about tobacco use, health, and gambling. Using multivariate regression, we examined associations between gambling, tobacco use behaviors, and mental and physical health. Past-year gamblers were more likely than non-gamblers to be current smokers (adjusted odds ratio [AOR] = 1.44, 95% confidence interval [CI] = 1.03, 2.01). Smokers who gambled had higher mean Heaviness of Smoking Index (HSI) scores (mean difference = +0.32, 95% CI = 0.04, 0.60), and more often reported smokeless tobacco use (AOR = 1.73, 95% CI = 1.16, 2.58), compared to non-gambling smokers. Past-year problem gamblers were more likely than all others (non-gamblers and non-problem gamblers) to be current smokers (AOR = 1.44, 95% CI = 1.08, 1.90) and to report high psychosocial stress (AOR = 1.87, 95% CI = 1.34, 2.61). Smokers with problem gambling also had higher HSI scores (mean difference = +0.54, 95% CI = 0.14, 0.95) compared to smokers without problem gambling. Gambling and problem gambling were associated with tobacco use and heavier smoking. SUD patients with gambling comorbidity may be heavier smokers and may need concurrent treatment for tobacco use and problem gambling. This study provides novel data regarding gambling and tobacco use behaviors among SUD patients.

A Pilot Replication Study ofImplementing an Equine-Assisted Services Program Within a VA Residential Substance Use Disorder Treatment Program.

Veterans have high rates of substance use disorders and other mental health conditions including post-traumatic stress disorder. Effective treatments for these conditions exist; however, high attrition rates and residual symptoms after completing treatment are common. Complementary treatment approaches could enhance treatment engagement and/or response among this population. We previously reported a study of one such intervention, an equine-assisted learning, and psychotherapy incorporating horses intervention provided to veterans admitted to a Veterans Health Care Administration residential substance abuse treatment program. The first aim of this study was to replicate the previous study assessing the safety, feasibility, and preliminary outcomes of this intervention. The second aim was to examine the effect of participants attending multiple intervention sessions. Participants were 94 veterans who participated in one to six sessions of a 3-4-hour program consisting of both equine-assisted learning and psychotherapy incorporating horses. Pre- and post-session administration of the Positive and Negative Affect Scale, State-Trait Anxiety Inventory, and Craving Experience Questionnaire was utilized to assess changes in affect, anxiety, and craving. Wilcoxon signed-rank or paired two-tailed t-tests were utilized for pre- to post-session comparisons of the outcome measures for sessions 1-4. Generalized linear mixed-effects (GLME) models were constructed to determine the impact of dosage. GLME models were constructed to determine the impact of dosage. As with our previous study, the intervention was safe and feasible to utilize for this population. There were statistically significant pre- to post-session improvements, with medium-to-large effect sizes, for sessions 1-3 for negative affect and sessions 1 and 2 for positive affect, anxiety, and craving. The GLME models revealed no statistical significance for any of the predictors. Taken together, this study and our previous investigation of this equine-assisted services intervention suggest that it is safe and feasible to utilize for veterans admitted to a residential substance abuse treatment program and we have now found short-term benefits in two separate studies. Thus, a randomized controlled trial of this intervention is warranted to demonstrate cause and effect and determine whether longer-term benefits are associated with the intervention. The finding that there was no additional benefit from attendance at more than two intervention sessions suggests that dose-response relationship studies of equine-assisted services interventions for veterans are needed.

“The relationship changed because I had changed”: Experiences and perceptions of friendships between women treated for substance use disorder in women-only residential programs

Historically, the notion of friendships between women has been replete with negative myths and perceptions. However, studies show that friendships between women contribute to their wellbeing as a source of support and empowerment. Social support is known to be a key factor during recovery from a substance use disorder (SUD). Previous studies have examined a variety of relationships, but less attention has been paid to friendships between women with SUD. This qualitative study examined the perceptions and experiences of friendship of 14 women who recovered from a SUD and were treated in women-only residential treatment programs (RTP) in Israel. Content analysis revealed four categories that paralleled their linear life-course from childhood to adulthood: social rejection and the longing for connection and acceptance, interest-based versus non-interest-based friendships, being distant versus becoming close, and friendships with “normative” women versus friendships with “clean addicts.” Each category is situated on a conceptual axis representing the tension between trust and mistrust, the unifying theme. These findings are best understood within the framework of relational cultural theory (RCT), which emphasizes the importance of relationships in people's lives. Therapists should consider the positive impact of friendships between women, as a theme during the therapy process.

Shared Family Care: Out-of-Home Care Programs for Serving Parents and Children Together

ABSTRACT Helping children and parents remain together, despite significant parent or child problems, is a key objective of child welfare services. One option is to place whole families together into out-of-home settings. We searched peer-reviewed and gray literature and solicited input from international networks to identify the range of family placement programs available. We identified three key types of “shared family care.” Shared Family Foster Care (SFFC) involves sharing of care and intensive modeling of effective parenting by a host family that engages in mentoring of the parent and parenting of the child. Shared Residential Care (SRC) programs involve sharing of care and intensive modeling of effective parenting by professional staff as they engage parents and children in what had often been child-only residential programs. Family Residential Treatment Programs (FRT) also place parents and children in residence together. FRT programs are often aligned with inpatient treatment units. Active programs that illustrate each type are described. Through this typology and detailed information of currently active shared family care programs, policymakers and program designers can consider which kinds of programs have the most potential for implementation and sustainability.

An Analysis of Irregular Discharges From Residential Treatment Programs in the Department of Veterans Affairs Health Care System.

Veteran populations are frequently diagnosed with mental health conditions such as substance use disorder and PTSD. These conditions are associated with adverse outcomes including a higher risk of suicide. The Veterans Health Administration (VHA) has designed a robust mental health system to address these concerns. Veterans can access mental health treatment in acute inpatient, residential, and outpatient settings. Residential programs play an important role in meeting the needs of veterans who need more structure and support. Residential specialty types in the VHA include general mental health, substance use disorder, PTSD, and homeless/work programs. These programs are affiliated with a DVA facility (i.e., medical center). Although residential care can improve outcomes, there is evidence that some patients are discharged from these settings before achieving the program endpoint. These unplanned discharges are referred to using language such as against medical advice, self-discharge, or irregular discharge. Concerningly, unplanned discharges are associated with patient harm including death by suicide. Although there is some initial evidence to locate factors that predict irregular discharge in VHA residential programs, no work has been done to examine features associated with irregular discharge in each residential specialty. We conducted a retrospective cohort study of patients who were discharged from VHA residential treatment programs between January 2018 and September 2022. We included the following covariates: Principal diagnosis, gender, age, race/ethnicity, number of physical health conditions, number of mental health diagnostic categories, marital status, risk of homelessness, urbanicity, and service connection. We considered two discharge types: Regular and irregular. We used logistic regression to determine the odds of irregular discharge using models stratified by bed specialty as well as combined odds ratios and 95% CIs across program specialties. The primary purposes are to identify factors that predict irregular discharge and to determine if the factors are consistent across bed specialties. In a secondary analysis, we calculated facility-level adjusted rates of irregular discharge, limiting to facilities with at least 50 discharges. We identified the amount of residual variation that exists between facilities after adjusting for patient factors. A total of 279 residential programs (78,588 patients representing 124,632 discharges) were included in the analysis. Substance use disorder and homeless/work programs were the most common specialty types. Both in the overall and stratified analyses, the number of mental health diagnostic categories and younger age were predictors of irregular discharge. In the facility analysis, there was substantial variation in irregular discharge rates across residential specialties even after adjusting for all patient factors. For example, PTSD programs had a mean adjusted irregular discharge rate of 15.3% (SD: 7.4; range: 2.1-31.2; coefficient of variation: 48.4%). Irregular discharge is a key concern in VHA residential care. Patient characteristics do not account for all of the observed variation in rates across residential specialty types. There is a need to develop specialty-specific measures of irregular discharge to learn about system-level factors that contribute to irregular discharge. These data can inform strategies to avoid harms associated with irregular discharge.

153 Comparison of cortisol concentrations between traditional group therapy and equine assisted psychotherapy for substance use disorder residential treatment patients

Equine assisted psychotherapy (EAP) is emerging as an effective supplemental substance use disorder (SUD) treatment due to documented improvements in treatment retention, patient-therapist alliances, and patient communication skills within the therapeutic environment. Benefits are attributed to decreased cortisol concentrations associated with horse interaction during the therapy process, however, there is limited research on stress parameters related to EAP during SUD recovery. Due to the prolific nature of this disorder, there is an urgency in exploring effective treatment options for SUD. Therefore, the purpose of this study was to investigate concentrations of cortisol in SUD patients within a residential treatment program participating in EAP compared with those participating in traditional group therapy. Salivary cortisol samples were collected from 2 sample populations of young adults: A) residential SUD patients (n = 18) before and after 2 successive weeks of EAP-supplemented therapy sessions and B) residential population of SUD patients (n = 5) before and after 2 successive weeks of traditional group therapy sessions. The impacts of treatment, week of sampling, and treatment by week interactions were analyzedusing a mixed linear model in SAS. Significance level was set at 0.05. No significant impacts of therapy type (P = 0.74), week of sampling (P = 0.69), or any week by treatment interactions (P = 0.86) on patient cortisol concentrations were observed over the 2 week period. Results indicate that despite the therapeutic environment moving to an outdoor setting and the inclusion of exercise in the form of horseback riding within the EAP sessions that EAP did not introduce additional stress responses reflected in the cortisol measures than that seen within the traditional therapeutic setting. As such, EAP presents an opportunity to offer an alternative therapeutic experience where traditional approaches may have faltered, however, further research is needed looking at a larger sample population and additional physiological measures to determine the complete physiological impact this therapy has on SUD patients in comparison to other forms of therapeutic interventions.

Violence and Suicidal/Nonsuicidal Self-Injury Among Adolescents Undergoing Residential Treatment: An Examination of the Predictive Validity of the SAVRY, START:AV, and VRS-YV.

Using a retrospective study design, predictive validity of the Structured Assessment of Violence Risk in Youth, Short-Term Assessment of Risk and Treatability: Adolescent Version (START: AV), and the Violence Risk Scale-Youth Version (VRS-YV) was examined among 87 adolescents referred to a residential treatment program. With few exceptions, moderate to high accuracy was achieved for the three measures in predicting violence and suicidal/nonsuicidal self-injury occurring during the adolescents' time in treatment. Accuracy of the measures peaked within 90 days for violence and gradually increased over the 180-day follow-up for suicidal/nonsuicidal self-injury. Dynamic factors were more predictive of repeated events involving violence relative to static/historical factors, whereas only factors from the START: AV were predictive of repeated events involving suicidal/nonsuicidal self-injury. These results emphasize the need for further examining the risk of adverse outcomes beyond violence among adolescents.

Comparative effectiveness of evidence-based psychotherapies for PTSD delivered in VA residential PTSD treatment.

Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are first-line treatments for posttraumatic stress disorder (PTSD). There have been few direct comparisons of CPT and PE intended to determine their comparative effectiveness, none of which have examined outcomes among military veterans receiving these treatments in a residential setting such as the Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Such work is essential given that these veterans are among the most complex and severely symptomatic patients with PTSD treated in VA. In this study we compared changes in PTSD and depressive symptoms across admission, discharge, four months and 12 months following discharge among veterans who received CPT or PE within VA RRTPs. Using linear mixed models conducted on program evaluation data derived from the electronic medical record and follow-up surveys, we compared self-reported PTSD and depressive symptom outcomes among 1130 veterans with PTSD who were treated with individual CPT (n = 832, 73.5%) or PE (n = 297, 26.5%) in VA PTSD RRTPs in fiscal years 2018-2020. PTSD and depressive symptom severity did not significantly differ at any time points. The CPT and PE groups both showed large-sized reductions in PTSD (CPT d = 1.41, PE d = 1.51) and depression (CPT d = 1.01, PE d = 1.09) from baseline to 12-month follow-up. Outcomes for PE and CPT do not differ among a highly complex population of veterans with severe PTSD and several comorbid conditions that can make it difficult to engage in treatment.