When treating individuals in the justice system with a substance use disorder (SUD), it is not unusual for them to present with antisocial personality disorder (ASPD) as well. Unfortunately, it is often left unaddressed and not treated in an integrated way. Countless research has been devoted to the co-occurring treatment of mental health and SUDs, but rarely do you see programs citing treatment of substance use, the behaviors that caused them to be involved in the justice system, and ASPD symptoms in an integrated way.
ASPD is a mental health condition characterized by a demonstrated inability to conform to lawful or ethical behavior and an egocentric lack of concern for others, exhibited by long-term patterns of manipulation and exploitation (APA, 2013). Other characteristic signs and symptoms of ASPD as noted in the DSM-5 are as follows:
While causes of ASPD are not exactly known, we do know that personalities are developed in early childhood with genetics and environment being factors. Risk factors also include being diagnosed with conduct disorders in childhood. There is also information that brain development is interrupted. Individuals with ASPD can demonstrate significant issues as a result of their disorder, such as spousal or child abuse or neglect, incarceration, homicidal or suicidal tendencies, homelessness, and premature death often as a result of violence. Researchers believe that certain biological factors may contribute as well; these could include abnormal chemistry in the nervous system and impairment in the prefrontal cortex area of the brain that affects judgment, decision making, planning, and impulsive and aggressive behavior (Skodol, 2019).
Some ASPD behaviors are often attributed to individuals’ substance use, as some of the characteristics are very similar, though different enough when closely examined. While manipulation and conning behaviors are key features of both ASPD and SUDs, individuals with ASPD can also be very charming and charismatic, using those skills to their advantage. Individuals with these symptoms can intimidate other individuals in treatment, overtake treatment groups, and challenge clinicians with their behaviors. Disruption to treatment programs can be significant.
During my many years treating this population, I have found that one of the most important aspects of successful treatment is assessment. If the assessment is wrong, the treatment will be wrong, which will significantly reduce positive outcomes.
I often ask professionals if they assess for ASPD when treating the SUD-affected population. The common response is, “Yes, we have information on their legal and family history.” Certainly, that information is helpful, but just because individuals have legal histories does not mean they have ASPD. I have found that the majority of treatment programs do not appropriately assess for ASPD, even though it has been shown that as many as 40.5 percent of those with ASPD were found to have some form of a co-occurring SUD (Lenzenweger, Lane, Loranger, & Kessler, 2007). Additionally, substance use is linked to around 78 percent of violent crimes, 83 percent of property crimes, and 77 percent of public disorders, probation/parole offenses, and almost 83 percent of domestic violence offenses, which often are related to ASPD (Skodol, 2019; Johnson, Obert, Rawson, McCann, & Ling, 2014).
I have typically distinguished individuals with these disorders in two categories. Group one are individuals who have SUDs and become involved in the justice system as a result of or because of their substance use, and group two are individuals who meet ASPD criteria and use substances (Matrix Institute, 2014). These two categories of individuals require different skill sets and treatment options, though treatment programs often treat them in the same way. Treatment for these individuals should be integrated and address the substance use, ASPD symptoms, and behaviors that got them involved in the justice system. While some treatment programs may address criminal behavior and SUDs, they do so in an isolated way instead of integrated. For instance, programs may choose a treatment model to address the criminal behavior and then another model to address the substance use. They are often separate in nature and do not give these individuals the opportunity to see how their behaviors and their substance use are connected. Many programs also do not adequately address ASPD behaviors in this process.
The ideal treatment for this population should utilize a comprehensive, integrated approach and include contingency management (CM), cognitive behavioral therapy (CBT), motivational interviewing (MI; with caution), group therapy, individual therapy, drug testing, family education/therapy, and medication-assisted treatment (MAT) when appropriate. It is also important to note that treatment interventions should be done at the right time in order to get the best treatment response. I have found that CM works very well with this population, as both substance use and criminal behavior respond to the reward system of the brain. I have treated individuals who got just as much of a rush from planning and acting on criminal behaviors as they did from substance use. It makes sense that they respond well to rewards when learning to change to prosocial and prorecovery behaviors.
MI is a highly-recommended treatment modality I use fairly consistently and a great clinical tool. However, it is important to be cautious with this approach while working with individuals with ASPD symptoms. While clinicians using MI work to assess ASPD- and SUD-affected individuals’ strengths and weaknesses, those individuals can and will use that to their advantage—they will also assess their clinicians’ strengths and weaknesses. Providers who are not experienced with MI and treating this population can easily be manipulated.
For individuals with ASPD and SUDs structure is also imperative, so having them schedule their day to promote having a prosocial and prorecovery day is effective. Research shows that if people stick to a schedule that promotes prosocial and prorecovery behaviors, the chances of them using or reoffending are slim (Johnson et al., 2014). In some instances, contracts are needed to ensure clarity of responsibilities and demonstrate accountability.
As a lead author for the Matrix Model for Treatment in Criminal Justice Settings (Johnson et al., 2014)—a comprehensive, integrated, manualized, evidence-based treatment model that uses CBT, CM, MI, group and individual sessions, family education and therapy, drug testing, MAT, support systems, and aftercare—I have certainly seen the successes and impact comprehensive treatment can have on individuals in treatment for ASPD and SUDs. While using treatment-as-usual modalities with a drug-court population, I had about a 50 percent relapse rate and 50 percent retention rate. After implementing all the aforementioned components in an integrated manner, my outcomes changed to an 11 percent relapse rate and an 84 percent retention rate (Johnson et al., 2014)—significantly improved outcomes. The high-risk potential of this population demands integrated care.
Even if programs choose other separate treatment models, it is important to include all the components in the treatment process to ensure the best possible treatment outcomes. This is a very treatable population that requires integrated approaches.
Donna Johnson, JD, ICADC, ICCJP, ICCDP-D, LADC, is the director of training for Clare Matrix in Santa Monica, California. She has written numerous magazine articles and has been featured on CBS Atlanta, PBS, CNN, and Fox News discussing various addiction issues. Johnson is the co-author of The Matrix Model for Criminal Justice. She has been a keynote speaker and speaker for numerous state and national conferences, including the National Association for Drug Court Professionals Conference, the National Conference on Addictive Disorders, and the United Kingdom and European Symposium on Addictive Disorders.