Correctional Treatment and Re-Entry Plan for PTSD and Substance Use Disorder (Clinical Case Studies Example)

Why mental health and substance use treatment in corrections matters

Correctional facilities have become some of the largest providers of mental health care in the United States. A systematic review of U.S. state prisons found that rates of serious mental illnesses, including major depression and posttraumatic stress disorder (PTSD), were far higher among incarcerated people than in the general population (Prins, 2014). Substance use disorders are even more common. Without treatment, people often leave prison with the same untreated conditions that contributed to their offense, and the weeks after release carry an extraordinary risk of overdose death (Binswanger et al., 2007). Effective correctional care therefore needs two connected plans: treatment during incarceration and a structured re-entry plan.

Selected disorder and case study

Disorder: posttraumatic stress disorder (PTSD) co-occurring with substance use disorders (SUD).

Case study: Doerfler, L. A., & Twigden, A. (2022). A case study of prolonged exposure for posttraumatic stress disorder with a Latino male with polysubstance use, severe depression, and anger in a residential substance use treatment program. Clinical Case Studies, 21(4), 308–323.

1. Summary of the individual

2. Interventions during incarceration

The plan follows the Risk-Need-Responsivity (RNR) model, the leading evidence-based framework for correctional rehabilitation: match the intensity of services to the person’s risk of reoffending (risk), target factors that drive offending, such as substance use, antisocial associates and anger (needs), and deliver interventions in a way that fits the person’s learning style, culture and mental health (responsivity) (Bonta & Andrews, 2017).

• Intake screening and assessment: screen for PTSD (PCL-5), depression (PHQ-9), suicide risk, opioid withdrawal and medical conditions, and complete a validated risk-needs assessment to guide program intensity (Bonta & Andrews, 2017).
• Medications for opioid use disorder (MOUD): start or continue buprenorphine, methadone or extended-release naltrexone in custody. When Rhode Island offered all three FDA-approved medications to incarcerated people, post-release overdose deaths fell by about 61% (Green et al., 2018).
• Trauma-focused therapy: Prolonged Exposure (PE) was effective for this client: he reported no substance urges during PE, no remaining PTSD or depression problems at discharge, and maintained abstinence and full-time work at one-year follow-up (Doerfler & Twigden, 2022). In a correctional setting, PE can be delivered once the client is stable, in a private and safe space, by a trained clinician. Integrated programs that address trauma and substance use together, such as Seeking Safety, are alternatives when exposure therapy is not feasible.
• Treatment of depression and anger: CBT, behavioral activation and anger management groups; psychiatric evaluation for an SSRI if depression persists.
• Substance use treatment: a therapeutic community or intensive outpatient-style program within the facility, relapse prevention planning and peer support (NA/AA, SMART Recovery).
• Criminogenic needs: cognitive-behavioral programs targeting antisocial attitudes and problem-solving, such as Moral Reconation Therapy or Thinking for a Change.
• Responsivity and culture: provide services in his preferred language (Spanish or English), use culturally responsive approaches that respect family (familismo) and community, and practice trauma-informed care, recognizing that strip searches, restraints and confinement can trigger PTSD symptoms.
• Education and employment: GED or vocational certificates and prison work programs to build skills for post-release employment.

3. Ethical considerations

4. Biopsychosocial factors affecting recidivism

Research on the RNR model identifies substance use, antisocial associates, unemployment and lack of prosocial leisure as key dynamic risk factors that, unlike static factors such as criminal history, can be changed through intervention (Bonta & Andrews, 2017).

5. Re-entry strategies

Re-entry planning should begin at admission, not on release day. SAMHSA’s guidelines for transitioning people with mental or substance use disorders from jail and prison emphasize assessing needs, planning for release, identifying community providers and coordinating care to avoid gaps in treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017).

• Warm handoff to community care: appointments scheduled before release with a community mental health center and an opioid treatment program or buprenorphine prescriber; a bridge supply of medication and naloxone at release.
• Health coverage: help enroll in Medicaid before release so medications and therapy continue without interruption.
• Housing: because he was previously homeless, arrange recovery or transitional housing, or supportive housing through a reentry program.
• Employment: connect with vocational rehabilitation, reentry employment programs and “second-chance” employers; build on skills learned in prison.
• Identification and benefits: obtain state ID, Social Security card and benefits before release.
• Case management and peer support: a reentry case manager and a peer recovery specialist with lived experience, ideally bilingual, to help navigate services.
• Family and community connection: involve supportive family members if he wishes; link him to Latino community organizations and recovery groups.
• Supervision collaboration: coordinate with parole to set realistic conditions that support treatment, such as counting treatment attendance as compliance, rather than technical violations that lead back to prison.
• Overdose prevention education: teach him and his family about reduced tolerance and naloxone use; the first two weeks after release carry the highest risk of overdose death (Binswanger et al., 2007).
• Continuing trauma care: continue PTSD and depression treatment in the community and review his relapse prevention and safety plans.

Justification of the plan

This plan is grounded in current research. The RNR model directs services toward the dynamic factors most likely to reduce reoffending (Bonta & Andrews, 2017). Prolonged Exposure directly targets the trauma that drove this client’s substance use and was effective in his documented case (Doerfler & Twigden, 2022). Providing MOUD in custody and continuing it after release saves lives (Green et al., 2018) and addresses the extreme overdose risk after release (Binswanger et al., 2007). Coordinated re-entry planning, as recommended by SAMHSA (2017), prevents the gaps in care, housing and income that commonly lead to relapse and re-arrest. Finally, adherence to the APA Ethics Code (2017) and forensic guidelines (APA, 2013) protects the client’s rights and dignity in a coercive setting.

Related reading: IPV and therapy, cultural humility and applying a counseling theory to a case.

Conclusion

For a 32-year-old Latino man with PTSD, polysubstance use, depression and anger, incarceration can either worsen untreated conditions or become a turning point. An effective plan combines thorough assessment, medications for opioid use disorder, trauma-focused therapy such as Prolonged Exposure, CBT for depression, anger and criminogenic thinking, and education and job training, all delivered ethically and with cultural responsiveness. Re-entry planning that begins early and secures treatment, housing, employment and social support addresses the biopsychosocial factors most closely linked to recidivism and gives this individual a realistic path to recovery and community life.

References

American Psychological Association. (2013). Specialty guidelines for forensic psychology. American Psychologist, 68(1), 7–19. https://doi.org/10.1037/a0029889

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code

Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J. G., & Koepsell, T. D. (2007). Release from prison—A high risk of death for former inmates. New England Journal of Medicine, 356(2), 157–165. https://doi.org/10.1056/NEJMsa064115

Bonta, J., & Andrews, D. A. (2017). The psychology of criminal conduct (6th ed.). Routledge.

Doerfler, L. A., & Twigden, A. (2022). A case study of prolonged exposure for posttraumatic stress disorder with a Latino male with polysubstance use, severe depression, and anger in a residential substance use treatment program. Clinical Case Studies, 21(4), 308–323. https://doi.org/10.1177/15346501211073600

Green, T. C., Clarke, J., Brinkley-Rubinstein, L., Marshall, B. D. L., Alexander-Scott, N., Boss, R., & Rich, J. D. (2018). Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry, 75(4), 405–407. https://doi.org/10.1001/jamapsychiatry.2017.4614

Prins, S. J. (2014). Prevalence of mental illnesses in US state prisons: A systematic review. Psychiatric Services, 65(7), 862–872. https://doi.org/10.1176/appi.ps.201300166

Substance Abuse and Mental Health Services Administration. (2017). Guidelines for successful transition of people with mental or substance use disorders from jail and prison: Implementation guide (SMA16-4998). https://library.samhsa.gov/product/guidelines-successful-transition-people-mental-or-substance-use-disorders-jail-and-prison