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As the global population ages, the proportion of individuals living with functional disability is increasing. Evidence suggests that functional disability is associated with worse health outcomes and is concentrated in populations with high rates of concurrent social risk factors such as criminal legal involvement (CLI), making it an increasingly important issue for advocates of health equity. To determine whether age is associated with functional disability in a nationally representative sample of United States adults with lifetime exposure to the criminal legal system. Cross-sectional survey data from the National Survey of Drug Use and Health, 2015–2019. Nationally representative survey data. US adults who reported lifetime history of arrest (N = 37,279). Respondents were categorized into age groups: younger adults (age 18–49); middle-aged adults (age 50–64); and older adults (age ≥ 65). Functional disability as measure by the World Health Organization Disability Assessment Score 2.0 (WHO-DAS 2.0). A higher score indicates a greater degree of functional disability. The sample included 37,279 US adults with lifetime CLI of whom 60.0 % were younger adults, 28.5 % were middle-aged adults, and 11.5 % were older adults. The mean, unadjusted functional disability score for younger adults was 5.0 (95 % CI, 4.9, 5.1); for middle-aged adults it was 4.2 (95 % CI, 4.0, 4.4); and for older adults it was 3.2 (95 % CI, 2.9, 3.5). In models adjusted for sociodemographic and clinical confounders, differences were attenuated but remained statistically significant, indicating increased functional disability in the younger age groups. Our findings suggest that among adults with CLI, functional disability is distributed by age in a pattern distinct from the general population. A large number of young adults have CLI, and the findings suggest that prevalence of functional disability is exceedingly high in this marginalized group. Future studies should examine if substance use and mental health conditions contribute to these findings, and policy makers should examine if flexible interventions tailored to the needs of those with disability improve reentry outcomes for young adults with CLI. • Criminal legal system involvement (CLI) is associated with worse health outcomes. • Younger adults with CLI had much higher functional disability than older adults. • In general population, older adults have higher degree of functional disability. • Younger adults with CLI had higher substance use disorder in the sample. [ABSTRACT FROM AUTHOR]

Objective: While social networks influence individuals with substance use disorders (SUDs), the mechanisms for such influence are under-explored among women who use drugs. This study triangulates the perspectives of criminal justice professionals, SUD treatment professionals, and women with past and current experiences with substance use to explore these dynamics. Method: We conducted semistructured interviews (N = 42) in 2022 with women with current or past opioid use disorder (n = 20), SUD treatment professionals (n = 12), and criminal justice professionals (n = 10) who work with women with opioid use disorder. Interviews centered around participants' backgrounds, perceived barriers and facilitators to medications for opioid use disorder (MOUD) treatment, and gender-specific issues in MOUD treatment. All interviews were audio-recorded, transcribed, and deidentified. We used a four-step qualitative data analysis process to code transcripts. Results: Across these participants' accounts, we identified mechanisms by which women's social networks influenced their opioid use trajectories: intergenerational substance use, family support and strain, intimate partner influence, and peer support and pressure. Overall, the emergent themes in the present study reflect the embedded nature of support within social systems. Women who had access to and engaged with various forms of social support tended to be those who use/used MOUD and self-identified as in recovery. Conclusions: Combining MOUD treatment with psychosocial interventions allows women to heal from trauma, learn effective coping skills, and receive valuable resources to support recovery. Interventions focusing on family resilience and peer recovery support can disrupt the cycle of addiction and promote MOUD treatment success. Public Health Significance Statement: Barriers to SUD treatment and recovery exist at many levels. Interventions focusing on family resilience, fostering a healthy intimate partner relationship among couples in which one or both partners use drugs, and peer recovery support are crucially needed. [ABSTRACT FROM AUTHOR]

This paper explores the experiences of survivors of intimate partner violence (IPV) who seek help or avoid help from both within and outside the criminal legal system (CLS). Data derived from 22 interviews reveal four types of help-seeking experiences: (1) addressing harm (2) increasing harm (3) mandating participation and (4) avoiding participation. These types reflect the interactions between the CLS and vulnerable populations who frequently mistrust the CLS but are compelled to interact with it. This typology uncovers the complex realities of survivors' contact with the CLS and suggests less harmful alternatives as desired by the participants in our sample. [ABSTRACT FROM AUTHOR]

Institutional betrayal (IB) is well-documented among survivors of gender-based violence seeking help and/or reporting incidents of violence in various settings, including college campuses and health care settings. Two of the most common institutions from which survivors seek help are the criminal and civil legal systems; however, less is known about the experiences of IB among survivors interfacing with those systems. Previous studies exploring IB have implemented the Institutional Betrayal Questionnaire (IBQ) and its various adaptations, but this scale has not yet been analyzed in the criminal or civil legal context, nor has it been analyzed among racially marginalized survivors. This paper explores the potential for utilizing the IBQ-Health among a sample of 199 Black and Hispanic survivors of intimate partner violence (IPV) who sought help from the criminal and/or civil legal system(s). An exploratory factor analysis was conducted to explore the fit of the measure to the data. Results suggest that the measure as it has previously been used does not demonstrate strong reliability or fit with this population or institution. Possible explanations and future directions are explored, including support for developing and piloting a new measure to assess IB among Black and Hispanic survivors of interpersonal violence who are seeking help from criminal and civil legal institutions. [ABSTRACT FROM AUTHOR]

Abstract Background Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Methods Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015–2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. Results For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06–1.31) but not older adults (IRR 0.99, 95% CI 0.85–1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08–1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Conclusion Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization.

Abstract Background Sexually transmitted infections are a significant, and growing, public health problem in this country – particularly among youth. Innovative strategies are needed to reduce the community burden of infection. Preliminary studies indicate that individuals involved in the criminal legal system have high rates of infection. While gaps exist in providing screening for incarcerated individuals, there are minimal efforts that have been initiated to screen individuals diverted from incarceration. In this study, we examined the STI risk profile and feasibility of screening for sexually transmitted infections for youth who were attending an alternative sentencing program after arrest for a minor offense. Youth were screened for chlamydia and gonorrhea using urine-based nucleic acid amplification tests. Results Of the 307 participants engaged in a program providing supportive services for criminal legal system involved youth at the Brooklyn Court House in New York City, 186 agreed to screening for sexually transmitted infections, and 8% were positive for chlamydia, gonorrhea, or both. Conclusions Screening programs within carceral settings have proven effective in identifying individuals with STIs. However, with policy changes diverting more young people away from incarceration and into community-based programs, innovative programs are needed to identify STIs among youth in these settings. Our findings indicate that it is feasible to conduct venue-based screening in these settings, and, doing so may identify youth in need of treatment and further evaluation.

Abstract At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS.

Background: Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Methods: Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015–2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. Results: For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06–1.31) but not older adults (IRR 0.99, 95% CI 0.85–1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08–1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Conclusion: Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization. [ABSTRACT FROM AUTHOR]

Many people involved with the United States criminal legal system have experienced trauma, the long-term effects of which can challenge capacity to recover, often resulting in an increased risk of contact with the criminal legal system. Training programs can help professionals improve their understanding of trauma and implement trauma-informed responses. Limited research exists on the impact of trauma-informed response training for criminal legal professionals (e.g., corrections officers, court personnel, and law enforcement), and less is known about the effectiveness of the train-the-trainer (TTT) model in this context. In this article, we describe a four-phase, mixed-methods evaluation of a trauma-informed response training program delivered in the context of a 16-h TTT event to 28 criminal legal professionals in the southwest United States. We examine pre- and post-training knowledge acquisition, training experience, and impact on participant behaviors and attitudes 60 days post-training. Results provide preliminary support for the positive impact of trauma-informed response training for criminal legal professionals. We discuss future directions for research on the effectiveness of trauma-informed response training for criminal legal professionals, including, critically, whether trauma-informed training contributes to improved outcomes for individuals involved with the criminal legal system. [ABSTRACT FROM AUTHOR]

Psychological research has failed to take accountability for the ways it has aligned with State interests, at the expense of solidarity with Black people protesting the criminal legal system and pursuing liberation in the U.S. Through a case study analysis of six psychological research articles, ranging from 1968 to 2022, this paper tracks evidence of psychology's alignment with the State's interests. Evidence emerges in clinical disease(s) assigned to enslaved and incarcerated Black people (drapetomania, protest psychosis) and in empirical assumptions and (il)logics binding research methods and analyses. While theoretical and methodological frameworks, language ("patients," "rioters," "ghetto residents," "minority group members") and levels of analysis (psyche, personality, social, community, identity, movement) evolve over time and across subdisciplines, racialized carceral ideologies persist across psychological research approaches. By tracing carceral footprints across this vast psychological literature, this analysis reveals how traditional empirical research weaponized pathologizing and criminalizing accounts to delegitimize Black protests of State violence from the Civil Rights Movement to the Movement for Black Lives and beyond. [ABSTRACT FROM AUTHOR]

Recent efforts to dismantle felon disenfranchisement regimes have the potential to substantially expand electoral eligibility among people with criminal records; however, even among those with criminal legal histories who are eligible to vote, voting rates are often extremely low. Analyzing interview, focus group, and text message conversations among a multi-state sample around the November 2022 election, we identify and describe how administrative barriers to voting—including a lack of understanding about the voting process, confusion about legal eligibility, and perceived risks of rearrest of voting while ineligible—pose an access to justice issue among system-impacted people. These barriers are amplified by government mistrust, specifically the perception that barriers are intentionally constructed to suppress voting, and they are potentially mitigated by outreach by community organizations that are viewed as credible. The findings emphasize that legislative reforms repealing disenfranchisement laws must be accompanied by on-the-ground efforts to address administrative burdens to broaden access to the franchise. [ABSTRACT FROM AUTHOR]

Since emerging in the late 1970s and early 1980s, neo-institutional theory has been a popular framework for understanding law, legal institutions, and policies on the books and in action. Neo-institutional theory has been particularly useful for explaining diverse criminal justice phenomena, from changes in penal law and policy statements to on-the-ground practices across police departments, courts, carceral facilities, and community corrections. This review describes how scholars of the criminal legal system have used neo-institutional theory and where there is room for further utilization. Additionally, it discusses how and why neo-institutional theory is particularly useful for sociolegal scholars, and not only those studying criminal legal organizations and policies. [ABSTRACT FROM AUTHOR]

Background: Sexually transmitted infections are a significant, and growing, public health problem in this country – particularly among youth. Innovative strategies are needed to reduce the community burden of infection. Preliminary studies indicate that individuals involved in the criminal legal system have high rates of infection. While gaps exist in providing screening for incarcerated individuals, there are minimal efforts that have been initiated to screen individuals diverted from incarceration. In this study, we examined the STI risk profile and feasibility of screening for sexually transmitted infections for youth who were attending an alternative sentencing program after arrest for a minor offense. Youth were screened for chlamydia and gonorrhea using urine-based nucleic acid amplification tests. Results: Of the 307 participants engaged in a program providing supportive services for criminal legal system involved youth at the Brooklyn Court House in New York City, 186 agreed to screening for sexually transmitted infections, and 8% were positive for chlamydia, gonorrhea, or both. Conclusions: Screening programs within carceral settings have proven effective in identifying individuals with STIs. However, with policy changes diverting more young people away from incarceration and into community-based programs, innovative programs are needed to identify STIs among youth in these settings. Our findings indicate that it is feasible to conduct venue-based screening in these settings, and, doing so may identify youth in need of treatment and further evaluation. [ABSTRACT FROM AUTHOR]

Black women in community supervision programs (CSPs) are disproportionately affected by HIV and other sexually transmitted infections (STIs). A randomized controlled trial of a group intervention titled Empowering African-American Women on the Road to Health (E-WORTH) demonstrated effectiveness in reducing sexual risk behaviors and STI incidence among Black women in CSPs. This secondary analysis aimed to assess the moderating effects of housing status and food security on E-WORTH effectiveness in reducing sexual risk behaviors and cumulative incidence of STIs over a 12-month period which were found significant in the original trial among a sample of 351 Black women in CSPs in New York City who use drugs and/or engage in binge drinking who reported engaging in HIV risk behaviors or testing positive for HIV. We examined the moderating effects of housing stability, housing independence, and food insecurity on reducing cumulative STI incidence and number of unprotected sex acts using mixed-effects negative binomial regression and logistic regression models that controlled for age, high school education, employment status, and marital status. Findings indicate that the intervention effect was moderated by housing stability, but not housing independence or food security. Compared to the control group, E-WORTH participants who were housing insecure had 63% fewer acts of condomless sex. Our findings highlight the importance of interventions designed for women in CSPs that account for upstream determinants of health and include service linkages to basic needs provisions. Further research is needed to unpack the cumulative impacts of multiple experiences of poverty faced by this population. [ABSTRACT FROM AUTHOR]

At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS. [ABSTRACT FROM AUTHOR]

Abstract Background Women with substance use disorders (SUDs) often experience adversity related to incarceration and reentry that can impact their substance use outcomes. This study aims to examine the adverse effects of incarceration and reentry on substance use outcomes among women with a history of opioid use disorder (OUD). Methods We carried out 42 semi-structured interviews (May–July 2022) with women with a history of criminal legal involvement and OUD (n = 20), criminal legal professionals (n = 10), and SUD treatment professionals (n = 12). The interviews focused on women’s substance use trajectories, barriers to treatment, and the intersection of the criminal legal system and treatment. None of the women were presently incarcerated during their interviews. Results Participants expressed the severe adverse impact of criminal legal involvement on women with OUD. Many women felt traumatized by experiencing detox while incarcerated, especially as they received minimal aid for withdrawal symptoms. Women seeking recovery while incarcerated felt unsupported, being afforded few treatment options, and experiencing stigma. Reentering society after incarceration also posed significant challenges to women’s individual recovery goals. Reentry-related challenges such as returning to unsupportive environments, facing difficulties finding employment, lacking secure housing, and facing the stigma of incarceration triggered adverse outcomes, such as relapse among those who were seeking to avoid illicit substances. Conclusions Findings suggest a need to evaluate detox protocols, medication for opioid use disorder (MOUD) access, and stigma in the criminal legal system. Interventions facilitating women’s reentry, reducing the combined stigma of incarceration and OUD, and restoring agency for women with OUD are also needed.

Background: Women with substance use disorders (SUDs) often experience adversity related to incarceration and reentry that can impact their substance use outcomes. This study aims to examine the adverse effects of incarceration and reentry on substance use outcomes among women with a history of opioid use disorder (OUD). Methods: We carried out 42 semi-structured interviews (May–July 2022) with women with a history of criminal legal involvement and OUD (n = 20), criminal legal professionals (n = 10), and SUD treatment professionals (n = 12). The interviews focused on women's substance use trajectories, barriers to treatment, and the intersection of the criminal legal system and treatment. None of the women were presently incarcerated during their interviews. Results: Participants expressed the severe adverse impact of criminal legal involvement on women with OUD. Many women felt traumatized by experiencing detox while incarcerated, especially as they received minimal aid for withdrawal symptoms. Women seeking recovery while incarcerated felt unsupported, being afforded few treatment options, and experiencing stigma. Reentering society after incarceration also posed significant challenges to women's individual recovery goals. Reentry-related challenges such as returning to unsupportive environments, facing difficulties finding employment, lacking secure housing, and facing the stigma of incarceration triggered adverse outcomes, such as relapse among those who were seeking to avoid illicit substances. Conclusions: Findings suggest a need to evaluate detox protocols, medication for opioid use disorder (MOUD) access, and stigma in the criminal legal system. Interventions facilitating women's reentry, reducing the combined stigma of incarceration and OUD, and restoring agency for women with OUD are also needed. [ABSTRACT FROM AUTHOR]

Incarcerated women in the United States commonly experience prison-based mental health treatment. Feminist scholars stress the need to explore how incarcerated women exercise agency while navigating controlling treatment dynamics and how they experience these dynamics in relation to aspects of their selves (e.g., their thoughts and feelings). To explore these dynamics, we conducted semi-structured individual interviews with 42 incarcerated women in a Midwestern state prison and with life history calendars, elucidated women's treatment encounters over time. Through analysis of these interviews, we contend that women experienced dehumanizing dynamics within treatment, particularly curtailed communication from the staff that silenced women, created unfamiliar selves, and contributed to physical harm and psychological harm. Based on these findings, we conceptualize prison-based mental health treatment as health harm rather than health care. We also found that women responded to controlling dynamics with forms of self-preservation including strategies of treatment decision-making that affirmed their selves, active treatment refusal as self-protection, and forming meaningful connections with others that validated aspects of their selves. Based on women's care-based strategies, further feminist theorizing and practice directions are needed that align with, build upon, and are guided by incarcerated women's varied definitions of care to improve their mental health and well-being. [ABSTRACT FROM AUTHOR]

This study sought to establish the feasibility of a two-component intervention embedded within a jail setting that would detect detainees with early psychosis and connect them to coordinated specialty care (CSC) in the community upon release. The two components of the intervention were a targeted educational campaign for correction officers and a specialized early engagement support service to facilitate jail discharge planning. Jail detainees with early psychosis were referred to the project and assessed for positive and negative symptoms, substance use, and duration of untreated psychosis (DUP). During a 24-month period, 25 individuals were referred, of whom eight were eligible and interviewed. The sociodemographic and clinical characteristics of the jail detainees were similar to those of individuals in hospital settings. The median DUP was 36 weeks. One of the eight detainees with early psychosis was successfully referred to CSC; for the other detainees, social or criminal legal factors precluded referral. A targeted educational campaign for correction officers and a specialized early engagement support service can be implemented in a jail setting, and referrals can be facilitated. Success of the campaign may depend on having dedicated liaisons within the jail setting (e.g., among correctional health staff) as well as liaisons in local CSC programs and leadership. Changes in the law and policy environments (e.g., criminal legal system reform) and changes in organizational practices and processes for corrections, correctional health, and local CSC programs (such as those made during the COVID-19 pandemic) require ongoing collaborations. [ABSTRACT FROM AUTHOR]

Abstract Background A growing body of research has called attention to limitations to reproductive autonomy in both women who are socially disadvantaged and in those who have had contact with the criminal legal (CL) system. However, it is unclear whether CL system contact influences contraceptive use patterns and how these processes unfold. We utilize a mixed-methods approach to investigate whether history of arrest is associated with receipt of contraceptive counseling, use of long-term contraception, sterilization, and subsequent desire for reversal of sterilization. We further consider how agents in and around the CL system may influence women’s reproductive decisions and outcomes (856 survey respondents; 10 interviewees). Results We observe that women who have been arrested more commonly report receipt of contraceptive counseling and sterilization. They are also significantly more likely to want their sterilization reversed. Our in-depth interviews suggest that women with CL contact experience considerable shame, and in some cases, coercion to limit fertility from various agents in and outside the criminal legal system including medical providers, Parole/Probation Officers (POs), guards, and family members. Conclusions Our findings suggest the need for ongoing attention to how exposure to this system may promote uneven use of certain forms of contraception and dissatisfaction, i.e., desire for reversal of sterilization, among these women. Findings further suggest that de-emphasizing the CL system as a means through which to address reproductive needs should be considered.

Background: Screening for fetal alcohol spectrum disorder (FASD) has been identified as a promising approach to improve recognition, understanding and effective response to the unique needs of those with FASD in criminal legal settings. However, to date, there has been limited synthesis of relevant screening tools, indicators, or implementation considerations in this context. Aims: The present review aimed to synthesise evidence and develop a conceptual framework for understanding how, when, why, for whom and by whom FASD screening tools, items and/or indicators and characteristics serve to accurately identify people with FASD in criminal legal contexts, with consideration of individual and system needs relevant to effective implementation and response. Methods: A preregistered search was conducted using a modified realist review framework for both peer‐reviewed articles and grey literature. Included sources were available in English, which focused on individuals with prenatal alcohol exposure and/or FASD with criminal legal involvement and offered new empirical evidence. Sources were reviewed using the Quality Control Tool for Screening Titles and Abstracts by Second Reviewer framework, extracted using a structured coding form and narratively synthesised. Results: The search yielded 52 sources, 11 FASD screening tools designed for or applied in criminal legal settings and 38 potential FASD indicators or characteristics relevant to identifying people who may have FASD in criminal legal settings, organised into six conceptually related domains. There was limited evidence supporting the psychometric properties of screening tools across populations or settings, though growing evidence highlights the promise of some instruments. Although few studies characterised potential considerations to be made when implementing a screening tool or approach, both system and individual level needs related to recognising and effectively responding to FASD in criminal legal contexts were identified, and findings revealed strong support among legal and clinical professionals regarding the need for FASD screening in these settings. Conclusions: Findings of this review can be used to inform the development, selection, implementation and evaluation of FASD screening tools in criminal legal settings and underscore a continued need for enhanced resources, policy and cross‐sectoral response to better support the needs of people with FASD in the criminal legal contexts. [ABSTRACT FROM AUTHOR]

This study explores how Black and Latinx young adults (ages 18–25) who were reentering the community from Los Angeles County jails viewed racial injustice in the criminal legal system in the context of the Black Lives Matter (BLM) protests of summer 2020. A sample of nine young adults participated in a series of up to nine monthly interviews between June 2020 and May 2021. The participants included seven young adults who identified as Black and two who identified as Latinx. Overall, participants held negative views of the criminal legal system and felt that police officers harmed Black and Brown people and communities. While most participants expressed support for the BLM protests, others doubted the protests as an effective tactic to address racial injustice. Even those who supported the protests described doubts about the possibility of genuine systemic changes in the criminal legal system and society. Findings pose implications for cultivating optimism for social change and countering legal cynicism among system-involved young adults. [ABSTRACT FROM AUTHOR]

Executive (dys)functioning is a known risk factor for offending behavior. A meta-analysis was conducted to understand differences in executive functioning across justice-involved and non-justice-involved groups. Across 37 studies, justice-involved groups performed significantly worse on measures of executive functioning compared with controls, with a random-effects grand mean effect size of Cohen's d = 0.55. However, 84.8% of the variance in effect size was due to between-study heterogeneity. Subgroup analyses and meta-regression were conducted to examine differences across age group (adult vs. adolescent), the measure of executive functioning, and intelligence quotient (IQ). Age group was a significant moderator such that there was a significant overall random-effects effect size for adults (Cohen's d = 0.72) but not for adolescents (Cohen's d = 0.18). The type of executive functioning measure and IQ were non-significant in random-effects models. Results indicate that, for adults, a robust difference in executive functioning performance exists between justice-involved and non-justice-involved groups. Clinical and correctional policy implications are discussed within the Risk-Needs-Responsivity framework. [ABSTRACT FROM AUTHOR]

Précis: Despite significant scholarship, research, and funding dedicated to implementing criminal diversion programs over the past two decades, persons with serious mental illness and substance use disorders remain substantially overrepresented in United States jails and prisons. Why are so many U.S. adults with behavioral health problems incarcerated instead of receiving treatment and other support to recover in the community? In this paper, we explore this persistent problem within the context of "relentless unmet need" in U.S. behavioral health (Alegría et al., 2021). [ABSTRACT FROM AUTHOR]

Individuals involved with the criminal legal system have higher rates of mental illness, addiction, and health care utilization. The authors examined whether substance use disorders and mental illness alone or in combination drive health care utilization among those with recent criminal legal involvement. This cross-sectional analysis used nationally representative data from U.S. adults with past-year criminal legal involvement (N=9,039) recorded in the National Survey on Drug Use and Health (2015–2019). Using adjusted negative binomial regression models, the authors estimated relative risks for health care utilization. Primary independent variable categories included neither substance use disorder nor mental illness, substance use disorder only, mental illness only, and both conditions. Health care utilization included emergency department (ED) visits and nights spent in inpatient care. Relative to neither mental illness nor substance use disorder, mental illness alone was associated with significantly increased acute health care services use: for ED visits, incidence risk ratio (IRR)=1.43 (95% CI=1.18–1.75) and for inpatient stays, IRR=2.14 (95% CI=1.47–3.11). Having both conditions was associated with increased ED visits (IRR=1.62, 95% CI=1.38–1.91) and inpatient stays (IRR=4.16, 95% CI=2.98–5.82). Substance use disorder alone was associated only with higher risk for ED visits compared with neither condition (IRR=1.23, 95% CI=1.01–1.50). Mental illness with or without co-occurring substance use disorder is a strong driver of acute health care utilization after interaction with the criminal legal system. Interventions tailored to the unique needs of individuals with mental illness or substance use disorder are needed for those with recent criminal legal involvement. [ABSTRACT FROM AUTHOR]

This study examines pathways from gender-based, racialized violence to health outcomes among formerly incarcerated Black women. We frame violence as gender-based and racialized, with a theoretical stance that we live in a male-dominated society characterized by historic and contemporary race-based oppression. This secondary analysis focused on a subsample of Black women (N = 288) from three U.S. cities (Oakland, CA; Kansas City, KS, MO; and Birmingham, AL) from March 2019 to June 2020 for the Tri-City Cervical Cancer Prevention Study among Women in the Justice System. Confirmatory factor analysis evaluated psychometric properties of hypothesized latent variables—violence victimization, living conditions, and healthcare access—and their observed indicators. Structural equation modeling estimated their relationships with physical, mental, and sexual health, controlling for sampling location. Violence victimization was associated with mental (β = 0.37, p =.000) and sexual health concerns (β = 0.31, p =.000). Healthcare access was associated with physical health concerns (β = 0.45, p =.004). Although there were no direct relationships between living conditions and health concerns, mediation analysis indicated worse living conditions were associated with more violence victimization and less healthcare access, with violence victimization fully mediating a relationship with mental and physical health concerns. Regarding control variables, women in Kansas City reported more sexual health concerns (β = 0.19, p =.005). Findings have important implications for treatment and care for Black women with incarceration and violence victimization histories. [ABSTRACT FROM AUTHOR]

Racial inequality has been a persistent component of American society since its inception. The present research investigates how lay beliefs about the nature of racism—as primarily caused by prejudiced individuals or, rather, to structural factors (i.e., policies, institutional practices) that disadvantage members of marginalized racial groups—predict reactions to evidence of racial inequality in the criminal legal system (Studies 1–3). Specifically, the current research suggests that holding a more structural (vs. interpersonal) view of racism predicts a greater tendency to perceive racial inequality in criminal legal outcomes. Moreover, White Americans' lay beliefs regarding racism, coupled with their general degree of preference for societal hierarchy, predict support for policies that would impact disparities in the U.S. prison population. Together, this work suggests that an appreciation of structural racism plays an important role in how people perceive and respond to racial inequality.

Despite reasons to believe that paternal incarceration has heterogeneous consequences for children, little research explores the processes underlying variation in children’s responses to this adverse event. We use data from the Jail and Family Life Study, an in-depth interview study of incarcerated fathers and their family members (including their children), to understand the heterogeneous processes linking paternal incarceration to children’s well-being. Children commonly reported that their father’s incarceration restructured their lives by altering their emotional and instrumental responsibilities. Within each of these domains, though, children expressed considerable variation in their responses, with some children seamlessly stepping into new responsibilities stemming from paternal incarceration and other children, especially older children who had witnessed their fathers’ frequent entanglements with the criminal legal system, consciously stepping away from these responsibilities. These findings illustrate the range of responses that children have to paternal incarceration, shedding light on processes that have not been observed in survey research.

This study examined whether expansions of Affordable Care Act (ACA) coverage led to changes in insurance coverage and behavioral health treatment use among adults with past-year criminal legal interactions. National Survey on Drug Use and Health data and a difference-in-differences design were used to compare changes in insurance coverage and behavioral health treatment use among respondents with a mental or substance use disorder, by past-year criminal legal involvement (N=103,818). Prior to ACA expansions, respondents with past-year criminal legal involvement (vs. without) were less likely to have insurance (61.5% vs. 79.3%) or to receive mental health treatment (34.7% vs. 36.3%). The ACA coverage expansions reduced insurance disparities for people with criminal legal involvement by almost 5 percentage points. No changes in behavioral health treatment use were found. Future policies that help people with criminal legal involvement get connected to coverage and treatment are warranted to address persistent disparities in coverage and treatment receipt. [ABSTRACT FROM AUTHOR]

Despite reasons to believe that paternal incarceration has heterogeneous consequences for children, little research explores the processes underlying variation in children's responses to this adverse event. We use data from the Jail and Family Life Study, an in-depth interview study of incarcerated fathers and their family members (including their children), to understand the heterogeneous processes linking paternal incarceration to children's well-being. Children commonly reported that their father's incarceration restructured their lives by altering their emotional and instrumental responsibilities. Within each of these domains, though, children expressed considerable variation in their responses, with some children seamlessly stepping into new responsibilities stemming from paternal incarceration and other children, especially older children who had witnessed their fathers' frequent entanglements with the criminal legal system, consciously stepping away from these responsibilities. These findings illustrate the range of responses that children have to paternal incarceration, shedding light on processes that have not been observed in survey research. [ABSTRACT FROM AUTHOR]

Jail incarceration substantially transforms romantic relationships, and incarceration may alter the commitment between partners, thereby undermining or strengthening relationships. In this article, we use in‐depth interviews with 85 women connected to incarcerated men (as current or former romantic partners) to explore how women articulate relationship changes that stem from their partner's jail incarceration, a common but understudied form of contact with the criminal legal system. We identify three interrelated and mutually reinforcing processes, which are shaped by and shape a partner's commitment to the relationship. First, incarceration produces liminality in the status of the relationship. Second, incarceration fosters women's sense of independence from their incarcerated partners. Third, incarceration creates space for partners to reevaluate how they prioritize the relationship in their lives. Jail incarceration intervenes in romantic relationships at different points during each relationship, and accordingly, women experience heterogeneity in processes of liminality, independence, and reprioritization. These processes contribute to differential relationship experiences, with some relationships deteriorating during incarceration, others strengthening, and others neither deteriorating nor strengthening. By systematically uncovering these processes linking jail incarceration to romantic relationships, we advance an understanding of how the criminal legal system can shape relationship commitment processes and inequalities among families. [ABSTRACT FROM AUTHOR]

Abstract Background We investigated the interaction between arrests for technical violations vs. receiving new charges with receiving community-based methadone treatment on time-to reincarceration (TTR) in a cohort of men with opioid use disorder (OUD) released from custody from two Connecticut jails from 2014 to 2018. Methods Hazard ratios (HR) were estimated for time to reincarceration for technical violations/infractions, misdemeanors only, felonies only, and both misdemeanors and felonies after adjusting for age, race/ethnicity, and receiving methadone treatment during incarceration or in the community following release. Moderation analyses tested the hypotheses that the benefits of receiving methadone in jail or the community on TTR were significantly different for people with only technical violations and infractions compared to misdemeanor and felony charges. Results In the sample of 788 men who were reincarcerated, 29.4% received technical violations with no new charges (n = 232) with the remainder of the sample receiving new charges consisting of 26.9% new misdemeanor charges, 6.5% felony charges, and 37.2% both felony and misdemeanor charges. Compared to men who received new misdemeanor charges, TTR was significantly shorter among those who received technical violations and infractions with no new charges amounting to a 50% increase in TTR (334.5 days, SD = 321.3 vs. 228.1 days, SD = 308.0, p

Abstract Background Stigma associated with substance use and criminal involvement is pervasive and creates a barrier to evidence-based addiction care within the criminal legal system. Research has yet to examine a multi-level stigma intervention which targets the intersection of these stigmas among both criminal legal staff and legally-involved clients. Methods This paper presents the protocol for a non-randomized trial of a multi-level stigma intervention called Combatting Stigma to Aid Reentry and Recovery (CSTARR) that involves two interventions: (1) training for criminal legal staff to address public stigma and (2) group-based acceptance and commitment therapy to address self-stigma among legally-involved adults enrolled in substance use treatment. Staff and client participants are engaged with a program called the Tennessee Recovery Oriented Compliance Strategy in 6 East Tennessee counties. This study examines the feasibility, acceptability, and preliminary effectiveness of CSTARR using a type 1 hybrid implementation/effectiveness trial with pre to post follow-up. Discussion Stigma must be addressed in the criminal legal system to facilitate the uptake of evidence-based addiction care. This study is the first to evaluate a stigma intervention designed for the criminal legal setting and results will be used to inform a larger, randomized controlled trial. The rationale for this study, research design and measures, as well as potential implications for the field are described. Trial registration This clinical trial is registered at clinicaltrials.gov with the identifier NCT05152342. Registered 11/5/2021 at https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000BIN8&selectaction=Edit&uid=U0005X4C&ts=2&cx=-u3wsbx .

Data from a unique survey of court-involved New Yorkers collected during the COVID-19 pandemic in 2020 provides evidence for a cycle of disadvantage involving penal control, material hardship, and health risk. We find evidence of chaotic jail conditions from March to May 2020 in the early phase of the pandemic, and high levels of housing and food insecurity, and joblessness for those leaving jail or with current criminal cases. The highest levels of material hardship—measured by housing insecurity, unemployment, shelter stays, and poor self-reported health—were experienced by those with mental illness and substance use problems who had been incarcerated.

There is a persistent disconnect between research and practice, both in the social work profession as well as in the criminal legal system. Community-engaged research has been suggested as an approach to bridge this divide, but specific tools are needed to integrate research and practice efforts. This article presents three distinct logic model development processes that occurred in collaborative research and practice efforts in the context of criminal legal programming, including prosecutor-led diversion programs, a high-intensity drug court, and a multiagency justice and mental health collaborative. Logic model development incorporated multiple forms of program information using collaborative reflexivity , an approach focused on understanding the relationship between knowledge and power in the research process. For each program, the authors describe the context and process of logic model development, and how the logic models were used by both practitioners and researchers. The authors discuss how collaborative logic model development can facilitate community-engaged research, strengthen the research–practice connection, and advance applied social work scholarship. [ABSTRACT FROM AUTHOR]

Background Prior studies demonstrate that eliminating hepatitis C virus (HCV) in the United States (US) heavily depends on treating incarcerated persons. Knowing the scope of the carceral HCV epidemic by state will help guide national elimination efforts. Methods Between 2019 and 2023, all state prison systems received surveys requesting data on hepatitis C antibody and viremic prevalence. We supplemented survey information with publicly available HCV data to corroborate responses and fill in data gaps. Results Weighting HCV prevalence by state prison population size, we estimate that 15.2% of the US prison population is HCV seropositive and 8.7% is viremic; 54.9% of seropositive persons have detectable RNA. Applying prevalence estimates to the total prison population at year-end 2021, 91 090 persons with HCV infection resided in a state prison. Conclusions With updated and more complete HCV data from all 50 states, HCV prevalence in state prisons is nearly 9-fold higher than the US general population. The heterogeneity in HCV prevalence by state prison system may reflect variable exposure before arrest and/or differences in treatment availability during incarceration. Elimination of HCV in the country depends on addressing the carceral epidemic, and one of the first steps is understanding the size of the problem. [ABSTRACT FROM AUTHOR]

Life course theories suggest that fathers' lifetime criminal legal system contact could contribute to poor parent–child outcomes via deterioration in couple relationship quality and fathers' behavioral health. Using paired, longitudinal data from the Multi-site Family Study (N = 1,112 couples), the current study examines the influence of three dimensions of fathers' life course legal system contact on individual and parent–child outcomes. In fitted models, accumulated system contact in adulthood predicts fathers' later depressive symptoms and drug misuse, which in turn predict diminished father–child relationship quality (as reported by both co-parents). Fathers who were older at the time of their first arrest had poorer relationships with their children's mothers and, in turn, poorer behavioral health and parent–child outcomes. Conditions of confinement during fathers' most recent prison stay do not significantly predict later parent–child outcomes, net of the influence of age at first arrest and accumulated criminal legal system contact in adulthood. [ABSTRACT FROM AUTHOR]

Objectives: Identifying ways to shift public attitudes toward support for alternative approaches to criminalized behavior is necessary to address mass incarceration. We test whether education on the impacts of traumatic events may be one strategy to increase such support. Drawing from mindset theory, we also test whether effects can be amplified through incorporation of growth mindset messaging. Methods: Two experimental studies assessed the impact of trauma education and growth mindset-enhanced trauma education on public attitudes. Results: In Study 1, participants in both trauma education conditions exhibited greater support for alternatives to incarceration for nonviolent crimes compared to the control condition. In Study 2, participants in the mindset-enhanced trauma education condition exhibited greater support for alternative sentencing for violent crimes compared to those in the other two conditions. Conclusions: Mindset-enhanced trauma education has potential to shift public attitudes toward support for alternative sentencing, though further research is needed to substantiate effects. [ABSTRACT FROM AUTHOR]

Aim: Given a lack of interventions to identify and engage individuals with early psychosis in jail and connect them to specialty care in the community upon release, we designed a Targeted Educational Campaign (TEC) for correction officers working in jails. We report on impacts of the TEC on officers' cognitive and attitudinal outcomes. Methods: Three different cohorts of officers—totaling n = 451—took part in a survey: 200 at baseline before the TEC began, 123 at 6‐months into the TEC, and 128 at 12‐months into the TEC. Among each cohort of officers, four constructs were measured: (1) knowledge about early psychosis; (2) self‐efficacy around detecting early psychosis and referring to mental health services within the jail; (3) expectations about the benefits of detection and referral to specialty care; and (4) social distance stigma toward detainees with early psychosis. Results: While exposure to TEC elements was as‐planned in the first 6‐months, exposure diminished substantially at 12‐months, coinciding with increasing fatigue among correction officers due to the COVID‐19 pandemic as well as serious staffing shortages. Knowledge, behavioural expectations, and self‐efficacy scores improved from baseline to 6‐months, with greater exposure to roll‐call messages driving scores. Knowledge and behavioural expectations at 12‐months were associated with having received an information post card. Social distance stigma worsened across timepoints. Conclusions: An educational campaign for jail staff can enhance knowledge, self‐efficacy, and behavioural expectations regarding early psychosis, though only while the campaign elements are active. Further research should investigate whether or not social distance stigma or other types of stigma increase alongside improvements. [ABSTRACT FROM AUTHOR]

Abstract Objective Pregnant women with criminal legal involvement and opioid use disorder (CL-OUD) living in non-urban regions may be at risk for complex biomedical, psychological, and social barriers to prenatal care and healthy pregnancy. Yet, limited research has explored prenatal care utilization patterns among this subpopulation. This study describes the biopsychosocial factors of pregnant women with a history of criminal legal involvement and opioid use disorder (CL-OUD) associated with timely prenatal care initiation and adequate prenatal care utilization (APNCU). Methods Analyses were conducted on a subsample of medical record data from an observational comparative effectiveness study of medication treatment models for pregnant women with diagnosed opioid use disorder (OUD) who received prenatal care in Northern New England between 2015 and 2022. The subsample included women aged ≥ 16 years with documented criminal legal involvement. Analyses included χ2, Fisher exact tests, and multiple logistic regression to assess differences in timely prenatal care and APNCU associated with biopsychosocial factors selected by backwards stepwise regression. Results Among 317 women with CL-OUD, 203 (64.0%) received timely prenatal care and 174 (54.9%) received adequate care. Timely prenatal care was associated with having two or three prior pregnancies (aOR 2.37, 95% CI 1.07–5.20), receiving buprenorphine at care initiation (aOR 1.85, 95% CI 1.01–3.41), having stable housing (aOR 2.49, 95% CI 1.41–4.41), and being mandated to court diversion (aOR 4.06, 95% CI 1.54–10.7) or community supervision (aOR 2.05, 95% CI 1.16–3.63). APNCU was associated with having a pregnancy-related medical condition (aOR 2.17, 95% CI 1.27–3.71), receiving MOUD throughout the entire prenatal care period (aOR 3.40, 95% CI 1.45–7.94), having a higher number of psychiatric diagnoses (aOR 1.35, 95% CI 1.07–1.70), attending a rurally-located prenatal care practice (aOR 2.14, 95% CI 1.22–3.76), having stable housing (aOR 1.94, 95% CI 1.06–3.54), and being mandated to court diversion (aOR 3.11, 95% CI 1.19–8.15). Conclusion While not causal, results suggest that timely and adequate prenatal care among women with CL-OUD may be supported by OUD treatment, comorbid indications for care, stable access to social resources, and maintained residence in the community (i.e., community-based alternatives to incarceration).

Abstract Background People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses. Methods System mapping exercises were conducted with misdemeanor system stakeholders from the jurisdictions of Atlanta, Chicago, Manhattan, and Philadelphia. Narrative detail on decision-making and case processing, both generally and in relation to specific types of behavior, including trespassing, retail theft/shoplifting, and simple assault, were coded and analyzed for thematic patterns. Based on the qualitative analysis, this paper offers a conceptual diagram of contexts shaping misdemeanor system interventions among people with mental illnesses. Results All four sites have been engaged in efforts to reduce the use of misdemeanor charges both generally and in relation to people with mental illnesses. Decision-makers across all sites experience contexts that shape how, when, and where they intervene, which are: (1) law and policy environments; (2) location of the behavior; (3) expectations of stakeholders; (4) knowledge of mental illnesses; and (5) access to community resources. Law and policy environments expand or constrain opportunities for diversion. The location of offending is relevant to who has a stake in the behavior, and what demands they have. Clinical, experiential, and system-level knowledge of mental illnesses inform a chain of decisions about what to do. The capacity to address mental health needs is contingent on access to social services, including housing. Conclusion People making decisions along the criminal legal continuum are critical to illuminating the dynamic, inter-related contexts that facilitate and frustrate attempts to address defendants’ mental health needs while balancing considerations of public safety. Multi-sector, scenario-based or case study exercises could help identify concrete ways of improving each of the contexts that surround whole-of-system decisions.

Background: We investigated the interaction between arrests for technical violations vs. receiving new charges with receiving community-based methadone treatment on time-to reincarceration (TTR) in a cohort of men with opioid use disorder (OUD) released from custody from two Connecticut jails from 2014 to 2018. Methods: Hazard ratios (HR) were estimated for time to reincarceration for technical violations/infractions, misdemeanors only, felonies only, and both misdemeanors and felonies after adjusting for age, race/ethnicity, and receiving methadone treatment during incarceration or in the community following release. Moderation analyses tested the hypotheses that the benefits of receiving methadone in jail or the community on TTR were significantly different for people with only technical violations and infractions compared to misdemeanor and felony charges. Results: In the sample of 788 men who were reincarcerated, 29.4% received technical violations with no new charges (n = 232) with the remainder of the sample receiving new charges consisting of 26.9% new misdemeanor charges, 6.5% felony charges, and 37.2% both felony and misdemeanor charges. Compared to men who received new misdemeanor charges, TTR was significantly shorter among those who received technical violations and infractions with no new charges amounting to a 50% increase in TTR (334.5 days, SD = 321.3 vs. 228.1 days, SD = 308.0, p < 0.001; aHR = 1.5, 95% CI = 1.3, 1.8, p < 0.001). TTR of men who resumed methadone and were charged with a new crime was 50% longer than those who resumed methadone and received technical violations/infractions with no new charges. (230.2 days, SD = 340.2 vs. 402.3 days, SD = 231.3; aHR = 1.5, 95%CI = 1.0, 2.2, p = 0.038). Conclusions: Reducing technical violations may enhance the benefits of providing community-based methadone following release from incarceration on extending the time between incarcerations during the vulnerable time post-incarceration and reduce the burden on correctional systems. [ABSTRACT FROM AUTHOR]

Policing and punishment are unevenly distributed across geographic space. Research analyzing place-based variation in the criminal legal system is increasing, asking how community conditions contribute to variation in criminal justice outcomes and how multiple criminal justice exposures (e.g., policing and punishment) vary together in places. In this article, we identify spatial-contextual analyses of the criminal legal system and summarize their contributions by organizing them by their three major approaches: those emphasizing crime, urban ecology, or social control. We describe challenges the subfield faces, including an overemphasis on large cities and an overcommitment to analyzing criminal justice institutions like police or prisons discretely, when they are often experienced cumulatively and simultaneously. We call for research that transcends received institutional divisions, generates recommendations for stakeholders at multiple scales, makes greater use of formal spatial modeling, and analyzes places across the urban-rural continuum. [ABSTRACT FROM AUTHOR]

Background: Stigma associated with substance use and criminal involvement is pervasive and creates a barrier to evidence-based addiction care within the criminal legal system. Research has yet to examine a multi-level stigma intervention which targets the intersection of these stigmas among both criminal legal staff and legally-involved clients. Methods: This paper presents the protocol for a non-randomized trial of a multi-level stigma intervention called Combatting Stigma to Aid Reentry and Recovery (CSTARR) that involves two interventions: (1) training for criminal legal staff to address public stigma and (2) group-based acceptance and commitment therapy to address self-stigma among legally-involved adults enrolled in substance use treatment. Staff and client participants are engaged with a program called the Tennessee Recovery Oriented Compliance Strategy in 6 East Tennessee counties. This study examines the feasibility, acceptability, and preliminary effectiveness of CSTARR using a type 1 hybrid implementation/effectiveness trial with pre to post follow-up. Discussion: Stigma must be addressed in the criminal legal system to facilitate the uptake of evidence-based addiction care. This study is the first to evaluate a stigma intervention designed for the criminal legal setting and results will be used to inform a larger, randomized controlled trial. The rationale for this study, research design and measures, as well as potential implications for the field are described. Trial registration: This clinical trial is registered at clinicaltrials.gov with the identifier NCT05152342. Registered 11/5/2021 at https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000BIN8&selectaction=Edit&uid=U0005X4C&ts=2&cx=-u3wsbx. [ABSTRACT FROM AUTHOR]

People with serious mental illnesses are disproportionately involved in the criminal legal system, often for low-level, non-violent misdemeanors. This paper examines how decision-makers at different stages of the criminal legal system articulate unique visions of the "best approach" for addressing this problem of over-representation. Focus groups and in-depth interviews were conducted with 94 stakeholders from Atlanta, Chicago, New York City, and Philadelphia to understand how decision-makers from different agencies use and process specific misdemeanor charges in relation to people with serious mental illnesses. Data were analyzed using a thematic approach. The data reveal a series of tensions regarding how criminal legal system stakeholders process people with serious mental illnesses through the misdemeanor system. Three key themes emerged from analysis. The first characterizes the shared commitment across agencies to reducing system contact among people with mental illnesses. The second explores how agencies differ on how to make good on that commitment because of the distinct values and goals they bring to the table. The final theme explores the limits of current approaches to reducing system contact for people with mental illnesses. Findings are discussed in the context of literature on "loose coupling" and the focal concerns framework and demonstrate that decisions about how and when to intervene with people with mental illnesses in the criminal legal system are influenced by the varying orientations, goals, and values of stakeholder agencies. Understanding these core differences is a critical step toward value alignment in strategies to reduce system involvement among people with mental illnesses. [ABSTRACT FROM AUTHOR]