Implementation Potential of Moral Reconation Therapy for Criminal Recidivism in Mental Health Residential Programs

A history of criminal justice involvement is common among patients in mental health residential treatment (1, 2), particularly among patients receiving care from the U.S. Veterans Health Administration (VHA). For example, 70%−75% of veterans in mental health treatment programs report a history of incarceration, most of whom report multiple lifetime charges (3–5). Links between mental illness and criminality are often driven by shared factors, such as adverse family environments, impoverished neighborhoods, and other societal forces (6–8). Mental illness, however, is a poor predictor of criminal recidivism, because justice-involved adults with mental illnesses have the same criminogenic risks as the general population of justice-involved adults (9). Accordingly, there is a need to implement interventions to reduce criminogenic risk among justice-involved adults with mental illness.

Cognitive-behavioral therapy (CBT) approaches to modify criminogenic thinking are considered best practices for reducing criminal recidivism among justice-involved adults (10–13). Criminogenic thinking is a robust risk factor for recidivism (10) and has been linked to criminal justice involvement among veterans (14–17). Moral reconation therapy (MRT) is a CBT- and group-based intervention for modifying criminogenic thinking (18) and has empirical support for reducing criminal recidivism among incarcerated adults (19, 20). Led by a trained facilitator, MRT includes open-enrollment groups that welcome new members at any time and uses a workbook to assist participants with completing 12 steps of moral development (e.g., healing damaged relationships and goal setting). Participants complete workbook assignments between group sessions and present their work at the next session. Completion of each MRT step takes approximately two sessions; thus, completion of all 12 steps of MRT requires participants to attend on average 24 sessions (18). A meta-analysis of 33 studies (20) observed that the recidivism rate was reduced by one-third among those who received MRT, relative to those in control conditions.

MRT was originally developed for individuals with substance use disorders in correctional settings (18). Less attention has been paid to the implementation potential of MRT for patients receiving mental health care in noncorrectional settings. Residential treatment programs may be an ideal context in which to study MRT implementation, because they serve a high proportion of justice-involved adults (5). However, barriers to patient engagement may exist when implementing MRT in residential settings (21), and provider concerns regarding MRT’s relevance for patients in these programs may be barriers to MRT adoption (22). It is also unclear how the facilitators of and challenges to implementation of MRT generally compare with those of CBT for individuals with mental illness (23, 24). For example, a study found (24) that implementation of a lifestyle intervention for inpatients with serious mental illness was facilitated by positive attitudes of staff and patients toward the intervention and that intervention complexity and lack of resources and organizational support were barriers to implementation.

The Present Study

We sought to identify facilitators of and barriers to implementing MRT in mental health residential treatment programs. We conducted a process evaluation to inform a multisite randomized controlled trial (RCT) on the effectiveness of MRT to reduce risk for recidivism among justice-involved veterans (25). The process evaluation was part of a hybrid 1 effectiveness-implementation trial, in which the primary focus was to test MRT’s effectiveness and also to gather data on its implementation potential to provide guidance to health care systems on best practices for wider implementation of MRT in mental health residential treatment programs. The evaluation was informed by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework (26), which includes collection of qualitative data from both patients and providers to identify factors that may affect an intervention’s potential for implementation and impact (27).

Methods

Design and Procedures

Parent RCT.

This study was conducted in the mental health residential treatment programs of three VHA medical centers. Patients were eligible if they had been arrested and charged or released from incarceration during the past 5 years. Across the sites, 341 patients were enrolled and randomly assigned to receive usual care in the residential program (N=169) or usual care in the residential program plus two MRT group meetings per week for 12 weeks (N=172). Usual care was comparable across sites and consisted of patients living in the program for 3–6 months, attending individual and group therapy sessions (7 hours per day, 5 days per week) to address mental health or substance use problems through CBT approaches (e.g., relapse prevention), and receiving case management or linkage to services to address employment and housing problems. Because of the high rates of posttraumatic stress disorder (PTSD) among veterans, some individual and group sessions also used evidence-based treatments for PTSD (e.g., cognitive processing therapy and prolonged exposure).

Process evaluation.

A one-time semistructured phone interview was conducted with patients who had been randomly assigned to the MRT condition and with frontline providers and leadership at each site who were involved in MRT’s implementation (referred to collectively as “staff”). For the patient sample, we enrolled a range of patients at each site; patients were selected on the basis of their level of engagement in MRT groups. Specifically, at month 12 of the RCT, the cross-site distribution of the number of MRT groups attended was reviewed to identify the lower, median, and upper quartiles to define low, moderate, and high levels of engagement, respectively. Low engagement was defined as attending three or fewer MRT group sessions, moderate engagement as attending six to nine sessions, and high engagement as attending ≥14 sessions. Using stratified purposeful sampling within these groups (28), we randomly selected patients at each site and contacted them by phone shortly after their participation in the MRT group had concluded. Using purposeful criterion sampling at each site, we reached out by phone to frontline providers who facilitated the MRT groups during the RCT and to residential program leadership after all MRT groups at that site had concluded. Phone interviews were conducted by research assistants and lasted approximately 30 minutes. All interviews were audio recorded (with the patients’ and staff members’ permission). Patient interviews were conducted from April 2017 to September 2018. Staff interviews were conducted from October 2018 to May 2019. All participants provided verbal informed consent, and all procedures were approved by the VA’s Central Institutional Review Board.

Sample

Sixty-eight patients were contacted and invited to participate. Of those contacted, 36 (53%) agreed to participate. Among these 36 patients, 13 (36%) were classified as low engagers in MRT, nine (25%) as moderate engagers, and 14 (39%) as high engagers. Patient participants had a mean±SD age of 48±12 years. Most of the patients were men (N=33, 92%), and their race-ethnicity was non-Hispanic White (N=18, 50%), Black or African American (N=13, 36%), Asian (N=1, 3%), Hispanic or Latinx (N=1, 3%), or Native American (N=1, 3%). Participants reported a lifetime median of nine criminal charges and 7.5 months of incarceration. According to the admission and discharge notes in their medical records, 97% (N=35) had been diagnosed as having a substance use disorder, 67% (N=24) as having PTSD, 64% (N=23) as having a mood disorder, 19% (N=7) as having an anxiety disorder, 14% (N=5) as having a personality disorder, and 89% (N=32) as having co-occurring substance use and mental disorders. At baseline, the mean T-score on the General Criminal Thinking index from the Psychological Inventory of Criminal Thinking Styles, calculated in reference to norms from incarcerated offenders (29), was 57.3±11.6, indicating a moderate level of criminal thinking.

Across sites, 15 staff members were contacted and invited to participate in the semistructured interview, of whom 13 (87%) agreed. Ten (77%) of those who agreed were frontline staff who had facilitated MRT groups during the trial, and three (23%) were residential program leaders who oversaw the implementation of the groups. These staff participants included six social workers (46%), two psychologists (15%), one psychiatrist (8%), one nurse manager (8%), one justice outreach specialist (8%), one peer specialist (8%), and one rehabilitation specialist (8%). Most of the staff participants were men (N=9, 69%) and non-Hispanic White (N=9, 69%).

Interview Guide

The patient and staff interviews were informed primarily by the RE-AIM framework (26), which consists of five domains for identifying factors that may influence an intervention’s potential for implementation and widespread impact: reach (how to reach the target population with the intervention), effectiveness (how to know the intervention is effective), adoption (organizational support for an intervention’s implementation), implementation (fidelity of an intervention’s delivery), and maintenance (sustainability of an intervention beyond a research study). The RE-AIM planning tool was used to ask questions of participants within these domains (30). Questions from the reach domain focus primarily on access rather than engagement. Because of the potential significance of the latter for MRT implementation in noncorrectional settings (21), we modified the tool to include a separate domain that focused on patient engagement. In addition, to more directly evaluate participants’ perceptions of the organizational fit of MRT for patients in residential treatment programs (22), we added the context domain from the Promoting Action on Research Implementation in Health Services (PARIHS) framework (31). Questions from the patient interview guide were focused on reach, patient engagement, effectiveness, and context. Questions from the staff interview guide focused on the same domains as the patient interviews, plus adoption, implementation (i.e., fidelity), and maintenance (see online supplement).

Analysis

Audio recordings of the patient and staff interviews were transcribed verbatim by a centralized transcription service in the VHA. Three of the study authors (D.M.B., J.S.S., S.J.) analyzed the transcripts by using the framework method, a form of content analysis that allows for systematic reduction of textual data (32, 33). To organize the textual data, this method uses matrixes, in which rows correspond to cases, columns correspond to interview questions or codes, and cells contain summaries of the data. In applying this method, separate matrixes were first created in Microsoft Excel for the patient and staff interviews. In each matrix, rows represented participants, and columns represented interview questions, grouped by implementation domain. Second, two analysts (J.S.S., S.J.) reviewed half of the transcripts and entered summaries of the data into the relevant cells of the spreadsheets. Each analyst then reviewed the entered data from the other analyst to confirm completeness and accuracy of the summarized content. Third, all three analysts independently reviewed 25% of both the patient and staff interview transcripts and developed an initial list of facilitators of and barriers to implementation of MRT in mental health residential treatment. This step included identifying actual facilitators of and barriers to implementing MRT during the trial, as well as potential facilitators and barriers to be explored in the future (initial review of the staff data revealed no differences in this analysis domain between frontline providers or leaders; therefore, the data from these respondents were combined). Fourth, the analysts used a consensus-based process to merge their independently derived facilitators of and barriers to implementing MRT. Fifth, each analyst reviewed the patient and staff matrixes and used the list of facilitators and barriers to code the relevant cells of the matrixes.

Coding meetings were held weekly to review consistency and to allow for addition of inductive codes (i.e., facilitators or barriers that emerged from additional review of the textual data). After consensus was reached, and the facilitators and barriers were revised to their final structure, the analysts independently assigned each facilitator or barrier to one of the implementation domains from the RE-AIM or PARIHS frameworks and engaged in a consensus process to rectify disagreements.

Results

Facilitators of Implementing MRT in Mental Health Residential Treatment Programs

The facilitators of implementation are described below. Illustrative quotes and the implementation domains corresponding to each facilitator are provided in Table 1.

Internal and external motivation.

Both patient and staff participants reported that internal and external motivation were key to the reach and patient engagement domains. Patients who had moderate or high levels of engagement in MRT noted that their own internal motivation to make changes in their lives was the driving factor for their participation. Staff participants highlighted the value of external motivators to patient engagement (e.g., court-related incentives for attendance) but also noted the importance of enhancing internal motivation for patients who had low engagement. For example, some staff noted that MRT does not contain any motivational interviewing components and suggested adding such elements to facilitate reach and patient engagement.

Complementarity with residential programming.

In the context of the adoption and context domains, patient and staff participants reported that MRT fit well with existing services in the residential programs and also added value. Staff participants liked that MRT followed principles of CBT and peer-support models of recovery but also filled a gap in programming by helping patients to consider how their thinking and behavioral choices contributed to their justice system involvement. All staff participants who facilitated MRT groups during the RCT expressed a desire for the groups to continue in their program after the trial. Patients with moderate and high levels of engagement in MRT also spoke positively about the content of the curriculum and felt that it was unique and complementary to the other services they received in the residential program.

Benefits beyond recidivism.

In terms of the effectiveness domain, although MRT is broadly focused on reducing risk for recidivism, participants reported other perceived benefits. For example, patients with moderate or high levels of engagement in MRT perceived that the therapy helped improve their decision-making and communication skills and, in turn, their relationships with others. Staff participants described MRT as having a positive impact on several areas of functioning, including substance use, mental health, employment, and housing. Furthermore, staff felt that MRT’s reach and adoption in other programs could be facilitated by promoting these benefits to generate buy-in from other staff and by offering the groups to residents who were not currently involved in the criminal justice system.

Broad network of collaborators.

To facilitate MRT adoption and maintenance in a residential program, staff participants stressed the value of creating partnerships with a broad network of collaborators. For example, staff noted the importance of collaborating with outpatient services in VHA to facilitate better continuity of care for patients entering and exiting the residential program. In addition, staff stressed the importance of creating partnerships with legal services, such as treatment courts, both inside and outside VHA.

Barriers to Implementing MRT in Residential Treatment Programs

The barriers to MRT implementation in mental health residential treatment programs are described below. Illustrative quotes and the implementation domains corresponding to each barrier are provided in Table 2.

Time-intensive curriculum.

Patient and staff participants viewed the length and intensity of the MRT curriculum as a barrier to patient engagement. Patients with low levels of MRT engagement reported that the workload was overwhelming, particularly because of competing demands from the residential program and other patient priorities (e.g., finding housing or employment). Both patient and staff participants also perceived MRT as an intervention that would function better as the foundation on which a residential program was designed rather than as a treatment incorporated into the program’s existing curriculum.

Challenges to adapting content and format.

Staff participants reported aspects of the MRT content and format that would present challenges to MRT adoption, implementation, and maintenance in residential programs. For example, some staff noted that, in contrast to other CBT-based curricula used in the program, MRT has rigid rules for step completion, such as memorization of testimonials, that are too difficult for those with cognitive impairment and presented challenges to full fidelity to MRT. Other staff noted that the group format limited opportunities for one-on-one sessions between group facilitators and group members. Staff participants also reported a need for the treatment protocol to be more flexible, either in terms of allowing only some MRT steps to be incorporated into the residential program curriculum as feasible, or creation of a condensed version of the protocol.

Long-term costs and required resources.

Staff participants highlighted the long-term costs and required resources for MRT maintenance in residential programs. For example, because the intervention is copyrighted by Correctional Counseling, Inc., funds are required to purchase the patient workbooks. Staff also reported that multiple group facilitators are needed to sustain an MRT group over time and noted the registration costs associated with training and certifying staff in MRT.

Discussion

This study sought to identify facilitators of and barriers to implementation of MRT in mental health residential treatment programs. Of particular interest was identifying factors that affected patient engagement in MRT. Across the reports from patient and staff participants, the time demands of the MRT curriculum were highlighted as a key factor for low patient engagement. In addition to the required therapeutic activities of those in residential treatment, patients often have other priorities, such as finding stable housing and employment before program discharge. Consequently, engagement in an intensive intervention such as MRT, which is focused on changing criminogenic thinking, may be perceived as lower on the hierarchy of needs for some patients. Similar challenges to engagement have been raised with other intensive interventions for substance use and mental disorders (34).

To boost patient engagement and expand the reach of MRT, staff participants stressed the importance of providing external motivation for group attendance as well as fostering patients’ internal motivations. Accordingly, it may be recommended that residential programs partner with a treatment court to provide external incentives for engagement in MRT (while being mindful of coercion) (35, 36). Programs may also consider pairing MRT with motivational interviewing to help patients consider the benefits of behavioral changes associated with criminal activity and to share in decision making to facilitate engagement (37, 38).

In regard to organizational support for MRT adoption, patient and staff participants uniformly viewed MRT as complementary to usual care in mental health residential treatment programs (i.e., grounded in a CBT approach and emphasis on peer support) but also as having incremental value to the standard curriculum of these programs, because of its focus on modifying criminogenic thinking. Further contributing to the potential for an organization to adopt MRT was the perception among both patients and staff members that the intervention could have benefits beyond recidivism reduction, particularly for outcomes that are more in the purview of residential treatment (i.e., substance use and mental health). With respect to effectiveness, it may be important to explore outcomes other than recidivism risk in future RCTs of MRT in residential treatment settings (e.g., interpersonal relationships). In regard to reach, it may be valuable to expand the eligibility for MRT groups in residential programs beyond individuals who have been recently or currently involved in the criminal justice system (e.g., on parole or probation). Alternatively, because of the increased history of arrest among veterans with co-occurring substance use and mental disorders (39), further adaptation of MRT for these patients to optimize implementation and clinical outcomes of the intervention may be needed. The high rates of PTSD among the sample also raise questions about the application of MRT to veterans versus nonveterans and the potential need to further adapt MRT for veterans with PTSD.

For mental health residential treatment programs that choose to adopt MRT, a key question is how to best implement it to ensure fidelity and long-term maintenance of the intervention. Given the intensive nature of MRT, one recommendation to facilitate implementation in the residential programs was to streamline the MRT content to allow programs to incorporate elements of the intervention as needed or to create a shortened version. Such efforts will require research to determine which elements of MRT could be modified without limiting the intervention’s effectiveness and which elements are core MRT components that should not be modified (40). To maintain MRT in a residential program over time, another recommendation was to establish a network of collaborators within and outside the health care system. For example, partnerships with entities of the criminal justice system, such as treatment courts, could provide a consistent referral stream into a residential program (21). The required costs of adopting and sustaining MRT are not trivial, however, and will require health care systems to account for the costs of the patient workbooks and staff training and certification.

We acknowledge some limitations of this study. First, the study was focused on justice-involved veterans receiving care in the VHA. Therefore, the extent to which our findings can be generalized to nonveterans or other health care systems is unclear. Nonetheless, the geographic diversity of the study sites likely enhanced the generalizability of the findings to other VHA mental health residential programs. Second, patients were not selected into the study on the basis of the level of criminogenic needs. Use of MRT among general arrestees may differ in indications for implementation than use among those with high criminogenic needs (e.g., general arrestees may perceive MRT as less relevant and may therefore engage less in the intervention). Notably, however, patient participants reported a moderate level of criminal thinking. Third, the current data could not speak to whether MRT is effective for reducing recidivism among residential patients, which is relevant to whether it is practical to implement MRT with this population. Fourth, although age was not reported as a factor affecting MRT acceptability, we note that the sample was middle-aged. Because engagement in criminal behaviors decreases with age, the impact of age on MRT acceptability should be explored in future studies.

Conclusions

Although MRT was viewed by both patients and staff as complementary to usual care in residential treatment programs, adaptations to the MRT curriculum are likely needed to facilitate implementation of the intervention on a wider scale. If such a modified version of MRT was shown to be effective, it could be combined with implementation strategies focused on establishing partnerships with services within and outside the health care system. Going forward, research on the implementation potential of MRT for justice-involved adults in mental health treatment must consider the larger context of the treatment needs (e.g., substance use, mental health, housing, and unemployment problems) that can increase risk for recidivism among patients in these settings (41). To merit more widespread implementation in residential programs, it will be necessary to establish that interventions such as MRT (which target criminogenic thinking) have a significant impact on reducing recidivism compared with other evidence-based treatments.