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Substance misuse is common among patients in the forensic mental health system, and this complicates their recovery and community reintegration.
A semi-structured manualized treatment program (SSMTP) is showing promise for treating patients who misuse drugs and alcohol and have multiple mental disorders in a forensic mental health setting. Research has found that SSMTP increased recognition of a problem and steps taken toward substance use cessation in this population. However, the program may be more effective for some substances than others.
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Olagunju, A. T., Sheridan, P., Fediuk, K. J., Harris, P., Oliveira-Picado, C., Bradford, J. M., & Chaimowitz, G. A. (2026). Psychopharmaco-psychosocial treatment for substance misuse among individuals in a Canadian forensic psychiatric program. Journal of Psychiatric Research, 193, 472–479. https://doi.org/10.1016/j.jpsychires.2025.11.042
Why Is the SSMTP Needed?
Substance misuse is directly linked with criminal behaviour. The odds of offending are three to four times higher for people who use drugs than those who do not. A significant proportion of people in forensic psychiatric services have substance use problems.
Comorbid substance use disorders (SUD) in forensic patients can complicate diagnosis, treatment, rehabilitation, and community integration. That’s because forensic patients with SUDs have longer hospital stays, significant criminal histories, antisocial behaviour, and a higher risk of violent reoffending.
Up to two-thirds of people with SUDs do not receive care. For those who do receive care, treatment is often challenging due to lower reported levels of impairment, perceived need for treatment, and motivation to seek treatment.
The efficacy of pharmacotherapy alone in ensuring abstinence for people with multiple disorders is limited, with poor uptake and early treatment discontinuation. Experts recommend forensic mental health clinicians take extra measures to improve therapy adherence. Clinicians should understand how best to integrate SUD treatment with pharmacotherapy and patient-related and other factors that influence treatment engagement and good outcomes.
What Is the SSMTP?
The Forensic Psychiatry Program at St. Joseph’s Healthcare Hamilton implemented the SSMTP for patients with multiple disorders to help them recognize how substance misuse affects their lives and encourage positive change. They based the program on motivational interviewing and cognitive behavioural therapies. The program provides individual and group counselling sessions.
Level 1 of the SSMTP is a pre-treatment program to assess patients’ substance use and attitudes toward change. It also provides education about the effects and risks of substance use and dependency and works to increase their commitment to changing their substance use behaviour.
Level 2 is an intensive treatment program that identifies triggers for patients’ substance use, develops strategies to cope and manage their behaviour without substances, develops a plan for anticipated lapses, and identifies needs and resources for future support.
Level 3 focuses on structured relapse prevention based on cognitive behavioural therapy to support patients in learning coping skills to deal with day-to-day substance use triggers effectively.
How Effective is the SSMTP?
Dr. Olagunju and colleagues reviewed data from patients with multiple disorders who participated in the SSMTP with psychopharmacological treatment in a forensic mental health facility. The researchers used the 19-item Stage of Change Readiness and Treatment Eagerness Scale (SOCRATES) to determine patients’ recognition of a problem, ambivalence (conflicting emotions about changing) about change, and taking steps toward change. Then they compare the SOCRATES scores from before and after treatment.
The researchers analyzed data from 96 patients, most of whom were male. Patients reported using cannabis, alcohol, nicotine, and cocaine, with a high level of poly-substance use.
For patients who reported using alcohol, recognition that alcohol was causing problems in their lives and steps taken did not significantly change between before and after treatment. While the degree of ambivalence was low among patients at both times, ambivalence significantly increased. The researchers say this reflects that patients were better able to consider the negative effects of alcohol use but felt more strongly that their drinking was not problematic. This lower perceived risk may be because fewer than a third of patients met the criteria for alcohol use disorder, even though nearly two-thirds of patients misused alcohol.
For patients using cannabis, cocaine, or tobacco, recognition increased significantly from before to after treatment. However, recognition was low for cocaine and tobacco at both times. Steps taken toward positive change also increased significantly in all three groups. The researchers say these two indicators suggest that SSMTP increased awareness of problematic use and influenced patients to take more steps toward positive change. However, there was no significant change in ambivalence about readiness to change. This finding may reflect the restricted use of cannabis, cocaine, and tobacco while in the forensic mental health system, even though patients were asked to complete the questionnaires as though they were free to do as they pleased.
Based on their findings, Dr. Olagunju and colleagues suggest that similar programs may be beneficial for forensic psychiatry patients with multiple disorders, especially for cannabis, cocaine, and tobacco use. The findings underscore the importance of integrated psychosocial programs for substance use with psychopharmacological treatment.
Written by Virginia St-Denis and approved by Dr. Andrew T. Olagunju.
