Improving Treatment Engagement and Outcomes Among Justice-involved Veterans
Phase: NA
Conditions: Antisocial Personality Disorder, Substance Use Disorder
Sponsor: VA Office of Research and Development

 
 
 
 
 
 
 
 
 
[Project ID: IIR 14-081]  
Improving Treatment Engagement and Outcomes among Justice-Involved Veterans 
Funding Agency: Health Services R&D 
Principal Investigator/Study Chair: Daniel M. Blonigen, Ph.D. 
 January 2, 2019

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 2 of 30 
 
 
Abstract 
Approximately 146,000 Veterans are released each year from correctional settings; however, 
two thirds will likely reoffend and return to the justice system. Antisocial cognitions and 
behaviors are the strongest predictors of reoffending and are highly prevalent among justice-
involved Veterans (JIVs). However, in the absence of treatments with demonstrated 
effectiveness with JIVs, no systematic approach to address antisocial cognitions and behaviors 
has been implemented in VA. Moral Reconation Therapy (MRT) is a cognitive-behavioral 
intervention that aims to reduce antisocial cognitions and behaviors. MRT has the best empirical 
support for reducing risk for criminal recidivism among civilian offenders, and its associated 
mechanisms have been linked to improvements in health-related outcomes that are also risk 
factors for recidivism (substance use, mental health, housing, and employment problems). 
However, no trials have been conducted with JIVs. Differences between JIVs and justice-
involved civilians suggests prior research on MRT with civilians may not be generalizable, and 
prompted the VA’s Veterans Justice Programs (VJP) and the developers of MRT to develop a 
Veteran-specific curriculum of this intervention. Testing this new MRT Veteran manual is a top 
priority of VJP. 
 
Using the new Veteran-specific manual, the overarching objective of the current proposal is to 
implement and evaluate MRT as an intervention to reduce risk for criminal recidivism and 
improve health-related outcomes among JIVs in VA Mental Health Residential Rehabilitation 
Treatment Programs (MH RRTPs). Using a Hybrid Type 1 design, this project will test the 
effectiveness of MRT in a multisite RCT (Palo Alto, Little Rock, and Bedford) and conduct a 
formative evaluation to facilitate future implementation of MRT in VA:  
 
Aim 1: A total of 365 Veterans who are being admitted to an MH RRTP, and had been arrested 
and charged and/or released from incarceration in the past 5 years, will complete a baseline 
assessment, be randomized to MRT or usual care (UC), and followed at 6 and 12 months post-
baseline. Hypotheses: Those in the MRT (vs. the UC) condition, will (1a) have a lower overall 
risk for criminal recidivism; (1b) have better health-related outcomes (substance use, mental 
health, housing, and employment); and (1c) the effects of MRT on reduced risk for recidivism 
and better health-related outcomes will be mediated in part by greater likelihood of completing 
the MH RRTP and utilizing substance use disorder and mental health continuing care services. 
 
Aim 2: Using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) 
framework, we will conduct qualitative interviews with 6 providers and 12 patients at each study 
site to identify (2a) barriers and facilitators to implementation of MRT in MH RRTPs across VA, 
and (2b) whether and/or how to adapt MRT to be most effective with diverse subpopulations of 
Veterans (e.g., OEF/OIF Veterans; women; racial/ethnic minorities; those with PTSD). Given 
that VA has not systematically implemented interventions that address antisocial cognitions and 
behaviors, this project fills a substantial gap in care for JIVs in VA, and therefore has significant 
potential to improve the long-term health of this vulnerable population.  
 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 3 of 30 
 
List of Abbreviations 
Addiction Severity Index (ASI) 
 
Center for Healthcare Organization and Implementation Research (CHOIR) 
Center for Innovation to Implementation (Ci2i) 
Center for Mental Healthcare and Outcomes Research (CeMHOR) 
Center of Innovation (COIN) 
Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) 
Criminal Thinking Scale (CTS) 
Fiscal Year (FY) 
Generalized Mixed-Effects Regression Models (GLMM) 
Health Services Research and Development (HSR&D) 
Homeless Operations Management System (HOMES) 
Institutional Review Board (IRB) 
International Classification of Diseases, Version 9 (ICD-9) 
Intervention Coordinator (IC) 
Investigator Initiated Research (IIR) 
Justice-Involved Veterans (JIV) 
Mental Health (MH) 
Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) 
Mental Health Services (MHS) 
Moral Reconation Therapy (MRT) 
National Center on Homelessness Among Veterans (NCHAV) 
National Institute of Health (NIH) 
National Patient Care Databases (NPCD) 
Office of Management and Budget (OMB) 
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
Organizational Readiness for Change Assessment (ORCA) 
Patient Treatment Files (PTF) 
Posttraumatic Stress Disorder (PTSD) 
Quality Enhancement Research Initiative (QUERI) 
Randomized Clinical Trials (RCT) 
Rapid Response Project (RRP) 
Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) 
Research and Development (R&D) 
Risk-Need-Responsivity (RNR) 
Scrambled Social Security Numbers (SCRSSN) 
Service Directed Project (SDP) 
Statistical Analysis System (SAS) 
Substance Use Disorder (SUD) 
Time-Line Follow Back (TLFB) 
Traumatic Brain Injuries (TBI) 
 
Usual Care (UC) 
Veterans Affairs (VA) 
Veterans Affairs Central Office (VACO) 
Veterans Informatics and Computing Infrastructure (VINCI) 
Veterans Justice Programs (VJP) 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 4 of 30 
 
Contents 
 
Protocol Title: ..............................................................................................................................5 
1.0 
Study Personnel ...............................................................................................................5 
2.0 
Introduction ......................................................................................................................5 
3.0 
Objectives ........................................................................................................................7 
4.0 
Resources and Personnel ................................................................................................7 
5.0 
Study Procedures .............................................................................................................8 
5.1 Study Design .....................................................................................................................8 
5.2 Recruitment Methods.......................................................................................................11 
5.3 Informed Consent Procedures .........................................................................................12 
5.4 Inclusion/Exclusion Criteria ..............................................................................................13 
5.5 Study Evaluations ............................................................................................................14 
5.6 Data Analysis ..................................................................................................................16 
5.7 Withdrawal of Subjects ....................................................................................................21 
6.0 
Reporting........................................................................................................................21 
7.0 
Privacy and Confidentiality .............................................................................................22 
8.0 
Communication Plan ......................................................................................................23 
9.0 
References ...................................................................................................................24 
 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 5 of 30 
 
Protocol Title:  Improving Treatment Engagement and Outcomes among Justice-involved 
Veterans 
1.0 
Study Personnel 
 
Principal Investigator/Study Chair:  
• 
Daniel M. Blonigen, PhD; Daniel.Blonigen@va.gov; VA Palo Alto; 8/8th VA employee 
Co-PI/SC:  
• 
David Smelson, PsyD; David.Smelson@va.gov; Bedford VAMC; 8/8th VA employee 
Co-Investigators:   
• 
Christine Timko, PhD; christine.timko@va.gov; VA Palo Alto; 8/8th VA employee 
• 
Michael Cucciare, PhD; michael.cucciare@va.gov; Little Rock VA; 6/8th VA employee 
• 
Eric Elbogen, PhD; eric.elbogen@va.gov; Durham VAMC; 5/8th VA employee 
2.0 
Introduction 
 
Veterans are a large and growing segment of offenders in the criminal justice system. US 
military Veterans represent 10% of those incarcerated in state and federal prisons 
(approximately 140,000 individuals), a rate that has increased by 71% over the past two 
decades.12 Given that approximately 75% of the correctional population in the US is on 
probation or parole13 and that many Veterans are arrested and charged but diverted from 
incarceration,76 these estimates represent only a fraction of the total number of “justice-involved 
Veterans” (JIVs) – i.e., those detained by, or under the supervision of, the criminal justice 
system.  
JIVs are at high risk for criminal recidivism. Approximately 146,000 Veterans are released each 
year from correctional settings,12 and many are in a chronic cycle of contact with the legal 
system. Data collected by the Veterans Justice Programs (VJP)–a branch of VA Office of 
Homelessness, which provides JIVs with outreach and linkage to VA services–show a lifetime 
average of eight criminal charges among Veterans served by these programs in FY11. 
Furthermore, two-thirds of offenders recidivate (i.e., are rearrested, reconvicted, or 
reincarcerated for a new crime or violation of their parole or probation) within three years from 
their release.1 Given that the proportion of those with a prior conviction is comparable across 
Veteran and non-Veteran inmates,4 the rate of recidivism among JIVs is likely comparable to 
that in the general population of offenders. 
Best practices for reducing criminal recidivism: Moral Reconation Therapy. Cognitive-behavioral 
interventions that are designed to restructure antisocial cognitions and behaviors represent best 
practices for reducing criminal recidivism.6,8,17,18 Antisocial cognitions and behaviors are the 
strongest predictors of reoffending3,19 and are highly prevalent among JIVs.20-23 The VA has not 
systematically implemented an intervention to address antisocial cognitions and behaviors. The 
VJP has highlighted this as a significant gap in care for JIVs.42 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 6 of 30 
 
 
Moral Reconation Therapy (MRT) is a cognitive-behavioral intervention that aims to reduce 
antisocial cognitions and behaviors,4 and has the best empirical support for reducing criminal 
recidivism among civilian offenders.23 MRT is a manualized intervention consisting of open-
enrollment group sessions that move participants through 12 steps. The curriculum was 
designed to be appropriate for those with lower reading skills or intellectual deficits, an 
advantage for working with Veterans with traumatic brain injuries (TBI).24 MRT was originally 
developed for drug therapeutic communities in prisons, which are analogous to VA Mental 
Health Residential Rehabilitation Treatment Programs (MH RRTPs). Prior to the common 
adaptation of the term “ego” in psychology in the 1930’s, the term “conation” was employed to 
describe the conscious process of decision-making and purposeful behavior. The term “moral 
reconation” was chosen for this system because the underlying goal was to change conscious 
decision-making to higher levels of moral reasoning.  
 
The evidence base for MRT in civilian samples. Multiple meta-analyses support the efficacy of 
MRT to reduce criminal recidivism.5-8,29,30 For example, in a review of 65 studies, MRT was 
found to reduce the 12-month recidivism rate by 50%.30 More recently, a meta-analysis of 33 
published studies of MRT found that (a) the rate of recidivism among MRT participants is 
reduced by one-third compared to those who do not receive MRT; (b) the treatment effect size 
is greater in randomized trials; (c) MRT is associated with significant reductions in recidivism in 
community settings,25-28,30,31 and (d) MRT is effective with a range of offender types.31,32 Further, 
the Palo Alto VA’s HSR&D Center for Innovation to Implementation (Ci2i) conducted a review of 
the evidence base for MRT in civilian samples.23 Using the Maryland Scale of Scientific 
Methods,33 six studies were identified as being rigorous enough to provide interpretable 
evidence about the impact of MRT (Level 3 or higher34). All six studies demonstrated a 
significant reduction in reoffending in the MRT group.25,26,35-38 Importantly, in community-based 
studies,25-28 MRT was delivered in structured therapeutic communities, which provided other 
intensive support services that may reduce risk for recidivism (e.g., substance abuse treatment; 
stress and anger management; family-support services; vocational skills training). 
Adaptation and testing of MRT with Veteran samples. Despite its evidence base in civilian 
samples, no randomized clinical trials (RCT) of MRT have been conducted with JIVs. This is an 
important research gap as JIVs differ from justice-involved civilians on sociodemographics (JIVs 
tend to be older, more educated, and more likely to be married);2,12 offense characteristics (JIVs 
are more likely to have committed violent offenses, particularly intimate partner violence); 2,12,70 
mental and physical health problems (JIVs have more service-related traumas and health issues, 
e.g., TBI), 71,77 and interpersonal problems (a strong connection to military culture in Veterans can 
increase feelings of estrangement from social networks upon return to civilian life).78 Given these 
differences, prior research on MRT with civilian populations may not be generalizable. Some 
MRT steps may, for example, need to go at a faster or slower pace, or include more focus on 
building trust and strengthening interpersonal relations.72 In response to this, the developers of 
MRT, in collaboration with VJP, developed a Veteran-specific curriculum for MRT, which was 
adapted to address the needs of JIVs.9 This version of MRT is beginning to be used in VA, but 
not in any systematic way because there has been no trial of its effectiveness with JIVs. Testing 
this version of MRT in Veterans is a top priority of VJP.  
MRT: Theoretical and empirical links to health-related outcomes. Aside from criminal recidivism, 
MRT has theoretical and empirical links to several health-related outcomes. For example, 
improvements in interpersonal functioning and impulse control–key mechanisms of MRT–
predict better substance use disorder (SUD) and mental health treatment outcomes,73 as well as 
better housing74 and employment outcomes.79 Consistent with this, MRT studies have reported 
improvements in SUD,25,39 mental health,28,40,41 and employment outcomes,25 and VJP 
Specialists who have piloted MRT groups with JIVs reported that Veterans who participated in 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 7 of 30 
 
these groups were more likely to utilize VA supportive housing services. Collectively, these 
findings provide the theoretical and empirical basis for how MRT is linked to health-related 
outcomes.  
 
The theoretical and empirical links between MRT and these health-related outcomes are 
important, given that (a) these health-related outcomes are risk factors for future recidivism, and 
(b) improvements in these outcomes have been shown to reduce recidivism. For example, 
according to the Risk-Need-Responsivity (RNR) model of offender rehabilitation,3 SUD and 
employment problems are robust predictors of criminal recidivism and key domains measured 
by valid indices of recidivism risk.75 In Veterans, more mental health problems predict risk of 
incarceration, above and beyond other established risk factors.15,16 Finally, Fontaine’s work 
suggests better housing outcomes as a path to successful reentry from incarceration.68,69 
3.0 
Objectives 
 
Using the new Veteran-specific manual, the overarching objective of the current proposal is to 
implement and evaluate Moral Reconation Therapy (MRT) as an intervention to reduce risk for 
criminal recidivism and improve health-related outcomes among justice-involved Veterans 
(JIVs) in VA Mental Health Residential Rehabilitation Treatment Programs (MH RRTPs). Using 
an effectiveness Hybrid Type 1 design, which incorporates both an RCT and a formative 
evaluation to facilitate future implementation, we will address two specific aims in this proposal: 
Aim 1: At three VA facilities (Palo Alto, Little Rock, and Bedford), randomize to MRT or usual 
care a total of 365 Veterans who (a) are being admitted to an MH RRTP in VA, and (b) had 
been arrested and charged and/or released from incarceration in the past 5 years. We 
hypothesize that, during the 12-month study period, those who receive MRT, relative to those 
who receive usual care, will:  
(1a) have a lower overall risk for criminal recidivism, operationalized via total scores on the 
General Criminal Thinking (GCT) index of the Psychological Inventory of Criminal Thinking 
Scale (PICTS), 
(1b) have better health-related outcomes (substance use, mental health, housing, and 
employment), and.  
(1c) the effects of MRT on reduced risk for recidivism and better health-related outcomes will be 
mediated in part by greater likelihood of completing the MH RRTP and utilizing substance use 
disorder and mental health continuing care services.  
Aim 2: Use the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) 
framework11 to conduct a formative evaluation of MRT (i.e., qualitative interviews with providers 
and patients). Such information will provide guidance to our operational partners in terms of 
broader adoption of MRT in VA, particularly with regard to identifying:  
(2a) barriers and facilitators to implementing MRT in MH RRTPs across VA.  
(2b) whether and/or how to adapt MRT for diverse subpopulations of Veterans (e.g., OEF/OIF 
Veterans; women; racial/ethnic minorities; those with PTSD). 
 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 8 of 30 
 
4.0 
Resources and Personnel 
 
This project will be conducted at three VA sites (Palo Alto, Little Rock, and Bedford). Dr. Daniel 
Blonigen (PI; Palo Alto VA) will oversee and direct all aspects of the study. He will prepare 
reports to disseminate the project findings to operational partners, organize regular meetings 
with project staff across sites and at the Palo Alto VA, and ensure that human subjects and data 
security regulations are followed. Dr. David Smelson (Co-PI; Bedford VA) will share 
responsibilities for project oversight with Dr. Blonigen. He will also oversee all project-related 
activities at the Bedford VA. Dr. Christine Timko (Co-Investigator; Palo Alto VA) will advise on 
project design and management and completion of study aims, as well as the interpretation, 
dissemination, and implementation of all project findings.  Dr. Michael Cucciare (Co-
Investigator) will serve as the site PI at the Little Rock VA and direct all project-related activities 
at this site, as well as advise on project design and management, and interpretation, 
dissemination and implementation of all project findings.  Dr. Eric Elbogen (Co-Investigator) will 
advise on the project design and management, particularly the sampling plan and assessment 
of recidivism risk, as well as the interpretation, dissemination and implementation of all project 
findings.  TBD Project Coordinator (Palo Alto VA) will help to prepare data collection protocols 
and materials during the project start-up period; recruit patients for both project aims; conduct 
baseline and follow-up assessments for Aim 1, and assist with qualitative interviews for Aim 2; 
check and code inventories and enter the data for both aims; and construct the project 
databases.  Three TBD Intervention Coordinators (Palo Alto, Little Rock, and Bedford) will 
prepare for, conduct, and maintain logs on the twice-weekly MRT groups, meet with the project 
team at Palo Alto, and participate in the monthly treatment fidelity calls with Dr. Robinson 
(Project Consultant and MRT co-developer) and the other Intervention Coordinators and site 
PIs.  Two TBD Research Health Science Specialists (Little Rock and Bedford) will help 
prepare data collection protocols and materials during the project start-up period; recruit 
patients for both project aims; conduct baseline and follow-up assessments for Aim 1 and assist 
with qualitative interviews for Aim 2; check and code inventories and enter the data for both 
aims; construct and manage the project databases; and meet with the project team at Little 
Rock. TBD Data Analyst (Palo Alto VA) will extract, clean, and organize health services 
utilization data from VA administrative databases, and create variables to test the relevant Aim 1 
hypotheses.  TBD Peer Trackers will utilize their social networks as well as utilize VistAWeb on 
a national level to uniquely assist the Project Manager at the Palo Alto VA with tracking difficult 
to reach participants at all sites who are lost to follow-up at 6- and 12-months.   
5.0 
Study Procedures 
 
5.1 
Study Design 
 
This study will use an effectiveness Hybrid Type 1 design10 to (Aim 1) test the effectiveness of 
MRT in an RCT across three VA sites (Palo Alto, Little Rock, and Bedford) and (Aim 2) gather 
information on MRT’s implementation potential in a formative evaluation. 
Aim 1: To test the effectiveness of MRT, 365 Veterans who (a) are entering an MH RRTP, and 
(b) had been arrested and charged and/or released from incarceration in the past 5 years will be 
recruited for participation and randomly assigned to one of two conditions: usual care (UC) in 
the MH RRTP or MRT (condition specifics outlined below). At the beginning of the study before 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 9 of 30 
 
participants are recruited, site PIs will generate a random number list using “randomizer.org” 
and create a randomization spreadsheet. Randomization will occur in blocks of six to prevent 
runs that might lead to unequal Ns if the full sample is not obtained. That is, we will use fixed 
block sizes of six to assure a roughly equal balance of subjects in the two conditions in case the 
study does not fully accrue. Following completion of the baseline assessment, the research 
assistant will add the participant to the randomization spreadsheet, notify the participant of 
his/her group assignment, and schedule the first MRT session for those randomized to that 
condition. Site PIs will review these procedures monthly with the research assistant to ensure 
fidelity to the process. To compare MRT to UC as UC actually exists in MH RRTPs, the number 
and length of project-related treatment sessions will not be equated between conditions. To 
reduce contamination, patients in the UC condition will not be allowed to attend MRT sessions, 
and the MRT group leader will remind the members at the end of each session not to discuss 
the group content outside of the session. Patients randomized to the UC condition will be asked 
not to seek out MRT during the study period of 1 year. 
UC condition. All patients, regardless of condition, will receive usual MH RRTP care at the Palo 
Alto, Little Rock, and Bedford VAs. At each site, we will recruit from residential treatment 
programs that serve veterans dealing with homelessness, substance abuse, and/or mental 
health issues. These MH RRTPs aim to improve Veterans’ health and facilitate community 
reintegration by providing care (24 hours per day, 7 days per week) using a structured 
residential environment. The participants’ health care providers at the MH RRTPs (not the study 
team) will be providing usual care.  No standard treatment will be withheld.   
MRT condition. Patients assigned to the MRT condition will receive usual care in the MH RRTP 
plus two hours of MRT weekly, which will begin within a week of entering the MH RRTP in order 
to complete all sessions during the 3-month program stay. Over the course of 12 weeks, they 
will attend 24 group sessions (one-hour sessions, twice per week). The overall length of the 
intervention (12 weeks) corresponds to the national average of bed days of care for Veterans in 
MH RRTPs (3 months). In FY13, an average of 70% of patients entering the MH RRTPs at the 
Palo Alto, Little Rock, and Bedford VAs stayed at least 90 days (approximately 13 weeks). 
Thus, the majority of patients will have full exposure to the 12-week intervention by virtue of 
staying in the MH RRTP. For the patients who do not stay for 12 weeks, continuing care 
services are still available at the MH RRTP at each site, and those who have not yet completed 
the full MRT protocol when they discharge from the MH RRTP will still be able to get full 
exposure to the intervention as outpatients, and will be encouraged to do so.   
The MRT curriculum consists of short assignments, grounded in cognitive-behavioral 
techniques, which move participants through 12 steps that aim to restructure antisocial 
cognitions and behaviors. To progress through the steps, patients complete homework between 
group meetings and at the next group each patient presents his/her homework to the group 
members for feedback. Participants move through steps at a rate of approximately 1-2 sessions 
and group sessions can incorporate new members at any time. With open enrollment, patients 
are presenting on different steps, which is advantageous because those who have progressed 
farther are able to share their insights to newer patients who are at lower steps. Open 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 10 of 30 
 
enrollment is also advantageous as it allows for recruitment of all eligible patients as they enter 
the MH RRTPs. 
The MRT groups will be facilitated by a combination of (a) members of the research team who 
are already listed in this application, (b) to-be-named (TBN) VJP Specialists from the local 
facility who are not MH RRTP staff, and (c) TBN staff members of the MH RRTP at each site. 
To reduce risk of contamination, the TBN staff members from the MH RRTPs will be specifically 
instructed to not provide the study intervention to any Veterans who were assigned to the usual 
care condition. 
A full dose of MRT is 24 sessions over 12 weeks. To facilitate patients’ completion of the full 
dose, we will (a) remind patients at the end of each MRT session about the treatment schedule 
and emphasize the importance of full participation;86 (b) contact patients who miss a session to 
determine the reasons for the absence and encourage participation in future sessions; (c) offer 
incentives (e.g., certificates) to patients who complete the full dose87,88 – such incentives are 
highly valued by Veterans as it allows them to demonstrate to court-related decision makers that 
they complied with treatment; (d) encourage participation in MRT groups as outpatients for 
those who have not yet completed the full dose when they discharge from the MH RRTP. These 
efforts notwithstanding, there is evidence that smaller doses of MRT can be effective (i.e., 
completion of seven steps in the MRT curriculum can lead to long-term positive changes).27,47 
According to Dr. Robinson and VJP Specialists who have run MRT groups, a minimum dose for 
this study is 12 sessions. To maximize clinical usefulness of the data, we will also examine 
outcomes as a function of dose. 
Aim 2:  The RE-AIM Planning Tool65 will be used to conduct semi-structured interviews with MH 
RRTP providers and patients at each site. The RE-AIM framework11 highlights five domains to 
evaluate an intervention’s potential for implementation and widespread impact: (1) Reach (how 
to reach the target population with the intervention); (2) Effectiveness (how to know the 
intervention is effective); (3) Adoption (organizational support); (4) Implementation (fidelity of 
intervention’s delivery); and (5) Maintenance (sustainability). The RE-AIM Planning Tool asks 
questions of providers and patients within each of these domains regarding key issues that 
should be considered when planning to implement an intervention.  
Staff from each of the site’s Domiciliaries will also be asked to complete the Context Scales of 
the Organizational Readiness to Change Assessment (ORCA), 23 items in total.  This 
assessment will help in understanding the context of care in regard to the MRT intervention that 
was implemented into the Domiciliaries.  
 
With assistance from Dr. Hagedorn (Project Consultant), Drs. Blonigen and Timko will prepare a 
draft interview guide for the formative evaluation, finalize it with feedback from the project team, 
and pre-test the interview with two MH RRTP staff members at the Palo Alto VA. We will 
interview six staff members at each site (the director, a nurse, a social worker, and a clinical 
psychologist or psychiatrist from the MH RRTP; a local VJP Specialist; and the local Mental 
Health Treatment Coordinator). A total of 18 VA staff members will be recruited for participation.  

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 11 of 30 
 
We will also conduct interviews with 12 JIVs from each site who agreed to participate in the 
study and were randomized to the MRT condition: (a) one-half will be drawn from those who 
completed the full dose (24 sessions) and the other half from those who dropped out and 
completed less than the recommended minimal dose (12 sessions).  
Sample sociodemographics. Based on the sociodemographics of JIVs from the project team 
members’ past studies of Veterans from VA MH RRTPs,43 we expect the sample for our 
proposed study to be predominantly male (97%), 48 years old, on average, and 46%, 24%, and 
14% will be Caucasian, African-American, and Hispanic, respectively. These estimates are 
highly comparable to the sociodemographics of Veterans in state and federal prisons that have 
been reported in national surveys,2,12,14 which suggests that the typical JIV seen in VA MH 
RRTPs is representative of the larger population of JIVs in the US.  
Some JIVs are economically and educationally disadvantaged and homeless. However, the 
number of such participants in our study is variable and would depend on the criteria for defining 
someone as disadvantaged. Due to our decision to include individuals with varied criminal 
justice involvement, it is important that we include a representative sample of JIVs entering a 
MH RRTP and, therefore, we must include such veterans in this study. If such individuals are 
not included in this study, we risk collecting ungeneralizable data, which (if used in clinical 
practice) could do harm to the patient population that was excluded from the study. 
Potential risks. It is possible that a few of the questions asked of patients (e.g., those inquiring 
about stressful life circumstances; alcohol and drug use; mental health symptoms; criminal 
history) may cause some psychological discomfort. However, such questions are not likely to be 
any more distressing than the questions that are typically asked of Veteran patients in MH 
RRTPs. The questions asked of VA staff will be limited to their perceptions of the 
implementation potential of MRT within MH RRTPs, possible adaptations for different 
subpopulations of Veterans, barriers associated with delivery of MRT during the RCT, and what 
modifications to MRT could be made to maximize effectiveness. These questions are not 
anticipated to cause any distress or harm. Therefore, the proposed project qualifies as a 
“minimal risk” research study according to 45 CFR 46.117(2)(c). Nonetheless, precautions will 
be taken to further minimize participants’ risks in the study. Specifically, during the informed 
consent process, participants will be told about the nature of our research study, the types of 
questions that will be asked of them, and the potential risks associated with these procedures. 
All participants will be given an opportunity to have any questions answered to their satisfaction 
prior to being asked to provide informed consent. 
Potential benefits. This research involves the risk of minor discomfort on the part of some 
participants. This risk, however, is more than offset by the potential benefits to the JIVs who 
participate in the study, which are (a) reducing risk for criminal recidivism, (b) improving health-
related outcomes (substance use, mental health, housing, and employment), and (c) increasing 
the likelihood of completing the MH RRTP and utilizing SUD/mental health continuing care 
services. We have conducted previous prospective studies with Veteran mental health patients 
in residential programs using these types of research procedures. In this prior work, no 
untoward events have occurred and no breaches of confidentiality have taken pace. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 12 of 30 
 
Project timeline. The proposed study will take 4 years to complete. The first 3 months will be 
used for the RCT’s start-up (e.g., staff MRT trainings; preparation of data collection protocols). 
Recruitment for the RCT will begin in Month 4 and during the next 24 months, 365 patients will 
be enrolled and complete baseline interviews. Follow-up assessments will begin 6 months after 
the first baseline assessment (Month 10) and end in Month 40. For the formative evaluation, we 
will recruit, conduct, transcribe, and code qualitative interviews with (a) patients from Months 18 
to 30, and (b) staff from Months 30 to 36.  Analyses of Aim 1 and 2 data, report writing, and 
dissemination of the primary findings of both aims to our operational partners will occur in 
Months 40-48. 
5.2 Recruitment Methods 
 
Aim 1: We will recruit participants through MH RRTPs at each site. Veterans entering these 
programs will be screened by MH RRTP staff in consecutive order during the admissions 
process to determine study eligibility.  Specifically, during the admissions process into the MH 
RRTP, a staff member will ask the Veteran if they were arrested and charged with a criminal 
offense and/or released from incarceration in the past 5 years. This is a standard question of all 
Veterans who enter MH RRTPs at each site. In addition, the MH RRTP staff member will verify 
that the Veteran is not pregnant and is conversant in English. MH RRTP staff will then ask 
eligible patients for permission to be contacted about the study by project staff (i.e., the MH 
RRTP staff member will hand the Veteran the Recruitment Sheet) and will provide study 
personnel with a list of these patients and their contact information (i.e., their phone number) 
three times per week. If the number of patients referred to the study exceeds recruitment goals, 
we will randomly select as many patients as needed.  At each site, we will keep a list of all 
eligible patients whom we contacted to solicit participation in the study. Prior to contacting a 
potential patient, we will first verify that that patient was not already approached about 
participating in the study during a previous admission.  
We plan to enroll approximately five patients per month at each site (approximately 1-2 patients 
per week). This approach aligns with standard delivery of MRT, which consists of open groups 
with rolling enrollment. The proposed pace will maintain appropriate group size for the MRT 
group facilitator and allow the research assistants to conduct assessments. 365 patients will be 
enrolled and complete baseline interviews. The sample will be stratified by site such that 122 
patients (with rounding) will be recruited separately from Palo Alto, Little Rock, and Bedford, 
with 61 patients entering into each condition at each site. Regardless of group assignment, 
participants will also be asked to complete an in-person baseline assessment and two follow-up 
assessments (in-person or via phone) 6 and 12 months later. Participants will be reimbursed 
$25 for the baseline interview, and $50 after completion of each follow-up interview.  
Participants will have the option of being reimbursed with gift cards immediately after the 
completion of each interview, or receiving a check via mail in 6-8 weeks. 
Aim 2 (Qualitative Interviews): We will interview six staff members at each site (the director, a 
nurse, a social worker, and a clinical psychologist or psychiatrist from the MH RRTP; a local 
VJP Specialist; and the local Mental Health Treatment Coordinator). We will also conduct 
interviews with 12 JIVs from each site who agreed to participate in the study and were 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 13 of 30 
 
randomized to the MRT condition: (a) one-half will be drawn from those who completed the full 
dose (24 sessions) and the other half from those who dropped out and completed less than the 
recommended minimal dose (12 sessions). Although individuals cannot represent entire groups, 
we will include a diverse sample of Veterans based on age, gender, race/ethnicity, era of 
military service, and diagnoses (e.g., PTSD). Interviews will last 30-60 minutes; be conducted in 
person or via phone by Drs. Blonigen and Timko, as well as the research assistants at each 
site; and audiotaped with consent. Staff interviews will take place after all patient participants 
have completed the intervention phase of the RCT.  Specifically, within two weeks of the last 
MRT session for patient participants at a given site, a research staff member at the site will 
attend MH RRTP staff meetings and distribute the information sheet that is included in this 
Central IRB application.  MH RRTP staff will then be informed that if they are interested in 
participating, they can contact the number listed at the bottom of the information sheet. Patient 
interviews will take place after participants have either completed or dropped out of the 
intervention.  Specifically, within 2 weeks of completing their last MRT session, patients will be 
re-contacted via phone and invited to participate in the 30-60 minute interview.   
5.3 Informed Consent Procedures 
 
Aim 1: Consent will be obtained by the site Project Coordinator, Intervention Coordinator, 
and/or Research Health Science Specialist who is knowledgeable about the study and trained to 
review the consent form with potential participants. Informed consent will be obtained in-person 
at one of the three VA sites (Palo Alto, Little Rock, and Bedford) prior to the start of the baseline 
assessment. At that time, the study will be explained in-depth and the research team member 
will go over all elements of the consent form with the patient. All patients will be given an 
opportunity to have any questions answered to their satisfaction prior to being asked to provide 
informed consent. Patients will be informed that they will be assigned either to “usual care” or 
two additional group sessions per week in the MH RRTP. The research team member will ask 
the potential participant questions to ensure that they understand the procedures and risks. The 
Research Assistants for this project (those listed in the personnel section) will be trained in 
Human Subjects protections and will have formally delegated responsibilities to obtain informed 
consent.  
 
Prior to entry into the study, patients will be told explicitly that should study personnel learn at 
any time that the patient poses a danger to self or others, the researchers will need to break 
confidentiality, which includes making a report to the proper authorities and/or providing 
additional help to the patient as dictated by VA regulations and state law. Providing patients with 
this information is a standard and integral part of the informed consent process for research 
studies with Veterans and has not deterred mental health patients from participating in our 
studies. Further, we will use methods developed in previous and ongoing RCTs and other 
studies of the project team members to ensure valid and informed consent – i.e., extensive 
training and monitoring of project staff obtaining consent; organizing the content of the consent 
form into separate modules; questioning prospective participants to determine the extent of their 
understanding of the study purpose, procedures, and risks; encouraging the patient to ask 
questions regarding anything not understood. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 14 of 30 
 
 
Aim 2: Veterans admitted to the MH RRTPs at the project sites who agreed to participate in the 
study and were randomized to the MRT condition, and either (a) completed a full dose of MRT 
(24 sessions), or (b) dropped out and completed less than the recommended minimal dose (12 
sessions), will be recruited to participate in the formative evaluation. VA staff members at each 
site (the director, a nurse, a social worker, and clinical psychologist or psychiatrist from the MH 
RRTP; a local VJP Specialist; and the local Mental Health Treatment Coordinator) will also be 
recruited for participation in the formative evaluation. The Veteran patients will be contacted by 
a member of the project team who will arrange to meet with the prospective participant to 
explain this portion of the project (see “Phone Script for Veterans”).  Written informed consent to 
participate in this part of the project will already have been obtained from the Veteran patients 
during the informed consent procedures for Aim 1.   
Verbal, rather than written, informed consent will be obtained from VA staff for Aim 2 (see 
Information Sheet – Waiver of Documentation of Informed Consent).  Specifically, a research 
staff member at each site will attend MH RRTP staff meetings and distribute the aforementioned 
Information Sheet.  MH RRTP staff will then be informed that if they are interested in 
participating, they can contact the number listed at the bottom of the Information Sheet.  VA 
staff members who contact a research staff member expressing interest in participating will then 
be read the phone script for VA providers. 
5.4 Inclusion/Exclusion Criteria 
Veterans who (a) are entering a mental health residential rehabilitation treatment 
program (MH RRTP) at one of three study sites (Palo Alto, Little Rock, or Bedford VA), 
and (b) had been arrested and charged and/or released from incarceration in the past 5 
years prior to MH RRTP admission will be eligible for participation. 
The only exclusion criterion is being too cognitively impaired to understand the informed 
consent process and other study procedures. Patients will be screened for cognitive 
impairment using the Montreal Cognitive Assessment’s section on Orientation. For 
patients who are not able to correctly answer the Orientation (date, location) items, the 
research assistant will further educate the patient on the purpose of the study and 
procedures until he or she is able to recall and reflect on these procedures. Patients who 
are unable to do so will be deemed too cognitively impaired to understand the study’s 
procedures, participate meaningfully in MRT, and respond to interviews, and therefore 
will be ineligible (in our past studies of Veterans from MH RRTPs, only 1% of 
prospective participants was excluded on this basis). For those who are eligible, written 
informed consent will be obtained, and the baseline assessment will be administered. 
5.5 Study Evaluations 
Baseline assessment. Research assistants will collect baseline self-report data on 
sociodemographics (e.g., age, gender, race/ethnicity, marital status, education, and 
income) and (a) recidivism risk and criminal history; (b) health-related functioning; (c) 
SUD/mental health treatment and mutual-help history; and (d) mechanisms of MRT. This 
assessment will be conducted in person at the MH RRTP and will take 60 minutes to 
complete. We will pre-test the assessment protocol to ensure that it can be completed 
within this timeframe. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 15 of 30 
 
Recidivism risk and criminal history. Recidivism risk will be measured with the 
Psychological Inventory of Criminal Thinking Styles (PICTS),75 which consists of 56 
items to assess antisocial cognitions and attitudes. These items are summed to create a 
General Criminal Thinking (GCT) score, which provides an overall index of recidivism 
risk. Scores on PICTS scores have good internal consistency,80,81  and, in the prediction 
of general recidivism (e.g., rearrests), multiple meta-analyses indicate that the validity of 
the PICTS GCT score is high and provides incremental prediction of this outcome above 
and beyond state risk factors such as age and criminal history, as well as interview-
based measures of recidivism risk (e.g., Level of Service Inventory).75,83   
Data on patients' criminal history, including type and recency of criminal justice 
involvement, will be obtained from a modified version of the legal section from the 
Addiction Severity Index (ASI)48 (i.e., age of first arrest and charge; number of times 
arrested and charged, number of times incarcerated, and total number of months 
incarcerated in past 12 months, past 5 years, and lifetime; number of months since most 
recent criminal justice event; and most recent offense for which the Veteran was 
arrested, charged, or incarcerated). We will verify the ASI legal section data using the 
HOMES assessments, which include information on criminal history and are 
administered to all patients entering VA MH RRTPs, and all patients served by VJP. 
Based on the empirical literature, patient reports of their criminal history are highly 
correlated with their criminal records.85 
Health-related functioning. We will use the ASI to assess substance use, and mental 
health, housing, and employment status at baseline. In addition to items on housing, the 
ASI assesses functioning in several problems areas, e.g., alcohol use, drug use, 
psychiatric, and employment. In each domain, items measure the number, extent, and 
duration of problems (lifetime and past 30 days). Composite scores are produced from 
sets of items that are standardized and summed (range from 0 to 1; higher scores 
indicate poorer outcomes), which provide internally-consistent indices of patient status in 
the relevant domains in the past 30 days. Prior work supports the validity of self-reports 
on these areas.50 To further assess substance use, the Time-Line Follow Back (TLFB) 
will be administered. The TLFB is a retrospective, calendar-based measure of substance 
use, which has been validated for administration in-person or via phone57 and will 
provide information on quantity and frequency of substance use in the 6 months prior to 
the baseline assessment (i.e., percent days of use; percent days abstinent; most 
consecutive days using; most consecutive days abstinent). To further assess psychiatric 
status, the PHQ-9 will be administered to assess symptoms of major depression, and 
the PTSD Checklist (DSM-V version) will be used to assess symptoms of PTSD.  VA 
records will be used to gather SUD and mental health diagnoses on patients at the time 
of admission to the MH RRTP, per ICD-9 codes linked to the appropriate bedsection 
code in the inpatient files. 
SUD/mental health treatment and mutual-help history. We will use the ASI to assess 
participants’ treatment history (i.e., any care [yes/no]; number of visits over the lifetime 
and past 12 months) for SUD (outpatient, residential, pharmacotherapy) and mental 
health (outpatient, inpatient, residential). Information on VA health services utilization in 
the past 12 months will be collected via patient records for these domains of care. Data 
on non-VA health care utilization will be collected to help determine whether the two 
condition arms are balanced and ensure that any changes in utilization of VA services 
are not due to changes in non-VA care. To measure attendance (yes/no; number of 
meetings) and involvement in mutual-help groups (lifetime, past 12 months) we will use 
items from the Alcoholics Anonymous Inventory.49 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 16 of 30 
 
Mechanisms of MRT. Interpersonal functioning will be assessed with the ASI 
family/social functioning composite, and a 32-item version of the self-report Inventory of 
Interpersonal Problems,54 which has good reliability and validity with mental health and 
criminal justice populations.55 Close affiliations with friends who (a) engage in criminal 
activity and (b) abuse drugs and alcohol will be assessed, respectively, with the 
Measures of Criminal Attitudes and Associates (MCAA) and select items from the Life 
Stressors and Social Resources Inventory (LISRES). 
Follow-up assessments. Research assistants, blinded to patients’ condition 
assignment, will collect self-report data from patients at 6 and 12 months. We will use an 
intent-to-treat design and follow all patients who are randomized to the MRT condition. 
To maximize retention, follow-up data will be collected via either phone or in-person 
interviews. Each follow-up interview will last 60 minutes, with the option of two shorter 
sessions if needed due to fatigue or scheduling issues. We will pre-test the assessment 
protocols to ensure that they can be completed within this timeframe.  For the Bedford 
site, upon completion of the 12-month follow-up visit, research staff will enter a close-out 
note in the participant’s VA health record. This note will confirm that the patient’s active 
participation in the study has ended. However, extraction of participants’ medical record 
data will continue beyond this point, as detailed in the HIPAA authorization form. 
Recidivism risk and recidivism. The PICTS is sensitive to change and will be 
readministered to assess overall risk for recidivism at the follow-ups. The ASI will also be 
readministered to measure criminal recidivism since the prior assessment (i.e., any 
arrest, incarceration, or violation of parole or probation; number of self-reported criminal 
acts regardless of whether an act was detected). ASI interviews can be conducted 
reliably and validly in-person or via phone.56 
Health-related functioning. The ASI will assess recent (past 30 days) functioning on the 
health-related outcomes using the sociodemographic information and composite scores. 
The Time-Line Follow Back (TLFB), a retrospective, calendar-based measure of 
substance use, will be re-administered at each follow-up assessment.  
MH RRTP completion and SUD/mental health continuing care utilization. MH RRTP 
completion will be determined from VA administrative databases. Data on SUD/mental 
health continuing care utilization since the prior assessment will be obtained from (a) VA 
administrative databases, for VA care; (b) an interview on non-VA health care utilization, 
for non-VA care; and (c) the Alcoholics Anonymous Inventory for mutual-help group 
attendance. From these data sources, we will calculate whether SUD/mental health care 
was received (yes/no) and the amount of care received (number of outpatient visits; 
number of mutual-help group meetings). To be comprehensive, we will also assess 
whether SUD or mental health inpatient/residential care occurred since the prior 
assessment (i.e., any care [yes/no], number of bed days of care). 
MRT mechanisms. We will re-administer the measures used at baseline to assess 
interpersonal functioning and affiliations with antisocial and substance abusing peers. 
Measuring utilization of VA health care services. We will collect data on patients’ use of 
VA health care (SUD; mental health) to test our hypothesis (i.e., effects of MRT will be 
mediated in part by service utilization). National data extracts from the Patient Treatment 
Files (PTF) and National Patient Care Databases (NPCD) will be used to determine 
utilization of VA residential (MH RRTP) and outpatient care. Corresponding information 
on utilization of VA-paid care at non-VA facilities is available in the national Fee Basis 
files and will be searched for all study participants. These datasets are maintained at 
VA’s Corporate Data Warehouse and available, in SAS format by fiscal year, through 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 17 of 30 
 
VA’s VINCI intranet site. We will obtain all PTF, NPCD, and Fee Basis files for study 
participants for all health care encounters that occur in a 12-month period prior to, and 
ending 12 months after, study enrollment. From the PTF files of residential care, we will 
extract the following data: patient ID (i.e., SCRSSN); station; treating specialty 
(bedsection); date of service; diagnostic and procedure codes; and length of stay. From 
the NPCD files of outpatient care, we will extract the following data: patient ID; station; 
clinic stop code; date of service; and diagnostic and procedure codes. Care identified in 
the Fee Basis files will be classified by setting and purpose of visit using several 
variables. Specifically, at each assessment we will ask patients to report on non-VA 
care, including type, timing, and duration of care. 
Arrest and incarceration records.  We will obtain state and federal arrest and 
incarceration records.  We anticipate that participants will be difficult to reach by phone 
or through alternate contacts and may have no current information in their VA medical 
health record.  This information is essential to determining if there is a difference 
between usual care and the MRT group, whether those in the treatment condition have a 
lower overall recidivism risk 
Fidelity assessments. To assess ongoing fidelity to the MRT condition, group sessions 
will be video- and audio-taped (with consent) and evaluated against a Fidelity Checklist 
by Dr. Blonigen and the other site PIs using the following schedule: (1) the first eight 
sessions for each IC, which corresponds to the first month of running MRT groups, will 
be assessed for protocol fidelity and the IC will be provided with corrective feedback; (2) 
one session for each IC will be reviewed at random each month by the site PI to ensure 
fidelity to the intervention. Dr. Robinson will also lead monthly treatment fidelity calls with 
the site PIs and ICs to (a) maintain adherence to the MRT protocol across sites, and (b) 
review the results of the de-identified MRT Fidelity Checklists that were completed by 
site PIs. For ICs who fall below an 80% rating on the checklist, a one-on-one, hour-long 
consultation with Dr. Robinson will be triggered to provide corrective feedback to the IC. 
Dr. Robinson has a protocol for fidelity drift, which he has used to retrain ICs in his past 
MRT studies. A follow-up, hour-long consultation with Dr. Robinson will take place two 
weeks later to review the IC’s progress. 
5.6 Data Analysis 
Sampling plan: Power analysis. To ensure sufficient variability in our outcomes, and in 
turn increase the power to test study hypotheses, we focused our Specific Aims on 
overall risk for recidivism (i.e., PICTS GCT total scores) and functioning on health-
related risk factors, rather than recidivism per se (e.g., rearrest), as the latter may have a 
low base rate within the 12-month study period. Based on meta-analyses7,8 and studies 
of MRT mechanisms,73 we expect a medium effect size (Cohen’s f2=.15)67 in multiple 
regression models testing condition (UC vs. MRT) as a predictor of recidivism risk and 
the health-related outcomes. However, given the planned moderation analyses, we 
calculated the power to detect small effect sizes (i.e., f2=.02). To account for having 
patients at three sites, power analyses using G*Power82 were based on having six cells 
(two conditions per site). A sample size of 292 (146 in each condition) will provide 80% 
power to detect a small effect size at an alpha of .05 (two-tailed test). To account for the 
moderators, we calculated the available power and effect size that could be detected in 
a regression model, given (a) our projected sample size, and (b) the addition of six more 
predictors in the model (i.e., the three moderator variables listed above and three 
interaction terms between these moderators and the variable of condition). Based on an 
N of 292 and alpha of .05, we would have 80% power to detect an f2 of .07, a small-to-

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 18 of 30 
 
medium size effect.67 We are predicting 20% attrition at the follow-ups. This was the rate 
of attrition in prior longitudinal studies of project team members of Veteran treatment 
samples with high rates of criminal histories.44-46 Thus, we will recruit a total of 365 
patients (183 in each condition, with rounding). If attrition reaches 30%, we will still have 
80% power to detect an f2 of .08. 
Procedures to locate and follow patients. To ensure high follow-up rates (>80%), we 
will adhere to well established procedures used by members of the project team for 
locating and following mental health patients in longitudinal studies who are homeless 
and have extensive criminal histories. Specifically, a form will be included in the baseline 
assessment to obtain information on patients’ mailing address, home/work/cell phone 
numbers, and employment information; contact information from a parole/probation 
officer, or case manager; and up to three additional individuals to be used in the event 
that contact with the participant is lost. This information will be collected and updated at 
all assessments. To complete follow-ups, project staff will persist in their efforts (for a 
minimum of three documented attempts) to locate a participant for the duration of the 
data collection period. These efforts will include mailing reminder cards to participants 
two weeks in advance of their scheduled follow-up interview. The card will include an 
800 telephone number for participants to call. Although some participants will be 
homeless, in our past studies, homeless participants often contacted us for follow-ups or 
were successfully contacted by project staff when returning for VA appointments. We 
also have connections with local homeless shelters and providers from VJP and VA 
supportive housing programs, which will greatly aid our ability to track participants. A 
participant will be considered “not located” only if s/he is not contacted at the time of the 
data lock. Once located, repeated attempts (a minimum of three) will be made to contact 
participants by phone and/or mail. 
We are confident we will be able to achieve an 80% response rate, given that we have 
achieved follow-up rates above 80% in prior longitudinal studies (e.g., 92% at a 1-year 
follow-up45; 84% at a 2-year follow-up46) using the same rigorous tracking procedures as 
proposed here with populations that had high rates of justice involvement and 
homelessness at intake. Further, in our current HSR&D study of Telephone Monitoring 
with dually-diagnosed psychiatric inpatients, 98% of participants have access to a phone 
for research assessments. To maximize retention, we will collect follow-up data via 
either telephone or in-person interviews, which will include visits to jails or prisons to 
interview participants who are incarcerated. We will use “peer trackers” to assist with 
locating clients, as they have social networks to track down participants and have been 
highly effective in our past studies. “Peer trackers” will also utilize the program, 
VistAWeb, on a national level to locate difficult to reach participants for the follow-up 
assessments. 
Aim 1: Analytic plan.  The project data will be analyzed at the Palo Alto VA by Drs. Blonigen 
and Timko. We hypothesize that those in the MRT (vs. the UC) condition will (1) have lower 
overall risk for criminal recidivism, and (2) better health-related outcomes (i.e., substance use, 
mental health, housing, and employment); and (3) the effects of MRT on reduced risk for 
recidivism and better health-related outcomes will be mediated in part by greater likelihood of 
completing the MH RRTP and utilizing SUD/mental health continuing care services. To test 
these hypotheses, we will do the following: 
Examine distributions. Generalized mixed-effects regression models (GLMM) will be conducted. 
However, prior to conducting these models, we will examine the distribution of the outcome and 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 19 of 30 
 
predictor variables. If non-normality in variable distributions is observed for the baseline 
comparisons between the UC and MRT conditions, we will use data transformation or 
nonparametric tests of equality between groups. One of the benefits of GLMM is its capacity to 
accommodate different conditional distributions for each outcome variable by choosing 
appropriate link and variance functions within GLMM. 
Examine baseline equivalence. We will use independent group t-tests and chi-square tests for 
continuous and categorical variables, respectively, to determine whether patients assigned to 
the UC and MRT conditions are comparable at baseline on (a) age, race/ethnicity, marital 
status, education, and income; (b) PICTS GCT scores; (b) substance use, mental health, 
housing, and employment status; (c) SUD/mental health treatment utilization and mutual-help 
group participation; and (d) percent incarcerated in the past 5 years, number of months since 
the most recent criminal justice event (i.e., charged or released from incarceration), and extent 
of criminal history (i.e., scores on a composite of number of charges, number of times 
incarcerated, and total number of months incarcerated). We do not anticipate baseline 
differences; however, if they are detected, the variables on which groups differ will be controlled 
in the regression analyses. 
Compare the UC and MRT conditions on study outcomes. We will use GLMM regressions to 
compare the UC and MRT conditions on overall risk for recidivism (PICTS GCT scores); and 
substance use (ASI alcohol and drug composites; TLFB scores), mental health (ASI psychiatric 
composite; PHQ-9 and PCL-5 scores), housing (ASI–number of months in a stable residence), 
and employment status (ASI employment composite) over the study period. GLMM models 
permit modeling of repeated-measures data; do not require that all participants be measured at 
all time points to be included in analyses; and apply to continuous, dichotomous (e.g., MH 
RRTP completion), and Poisson-distributed outcomes (e.g., number of SUD/mental health 
outpatient visits).58 
In the regression model, we will take into account that the repeated measures over the three 
time points are clustered within each individual by treating time as a single repeated factor. The 
main factor of interest is condition (UC, MRT). For each dependent variable, a linear trajectory 
for each patient will be estimated. The intercept is the estimate of the patient’s score at 
baseline. The slope is the estimate of the linear response trajectory and the error term 
represents how well the linear model fits the patient’s data. For each outcome, three between-
person parameters will be estimated: (a) the average baseline score for each group (UC, MRT); 
(b) the average slopes over time for the UC and MRT groups; and (c) the interaction of condition 
by site. We will employ full maximum likelihood estimation, and, in combination with random 
effects, we will examine further constraints on covariance structure (e.g., auto-regressive) and 
choose that which yields the best fit by standard goodness-of-fit indices (e.g., Akaike’s 
Information Criterion). 
As part of the model building process, we will examine the error distributions to assess whether 
random effects meet the assumptions of normality and homoscedasticity and adjust the models 
as needed. We will specify the appropriate distribution of the outcome variable in the regression 
model (normal, binomial, Poisson) and choose the appropriate link and variance functions. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 20 of 30 
 
Because the MRT intervention will be standardized and monitored for fidelity, we do not expect 
variations in outcomes associated with ICs across sites. However, to examine this possibility we 
will specify a model where random effects of patients are nested within random effects of the 
ICs. If the fit of the model is similar to one without nesting, we will not continue to control for it.59 
Examine moderators. For the direct effects of condition (UC, MRT) on study outcomes (overall 
risk for recidivism; and substance use, mental health, housing, and employment status), we will 
test three moderators of these effects: (a) incarcerated or not in the past 12 months; (b) number 
of months since the most recent criminal justice event (i.e., charged or released from 
incarceration); (c) an index of extent of criminal history (i.e., a z-scored composite of number of 
charges, number of times incarcerated, and total number of months incarcerated in lifetime). 
The continuous moderators (number of months since the most recent criminal justice event, and 
index of criminal history) will be zero-centered. The main effects of these moderator variables 
and the interaction terms between condition (UC, MRT) and each moderator will be entered into 
the same regression models described above. If any interaction terms are significant, 
conditional moderators will be evaluated to assess the direction and magnitude of effects within 
subgroups (e.g., re-entry subgroup).66  
Examine mechanisms (i.e., reasons MRT is effective). MH RRTP completion (yes/no) and 
SUD/mental health continuing care utilization (outpatient attendance [yes/no] and amount; 
mutual-help group attendance [yes/no], number of meetings) will be examined as mediators 
between condition and risk for recidivism, and between condition and the health-related 
outcomes at the 6- and 12-month follow-ups.60,61 We will conduct regression models that 
correspond to a hypothesized causal sequence among (1) MRT, (2) one of our hypothesized 
mediators, and (3) better outcomes. In each model, we will control for relevant covariates (e.g., 
baseline values for sociodemographics and the dependent variable). In the first regression, a 
dummy variable representing the MRT intervention will be the independent variable and the 
dependent variable will be the outcome (e.g., PICTS GCT scores). In the second regression, 
MRT will be the independent variable and the dependent variable will be the potential mediator. 
In the third regression, the potential mediator will be the independent variable and the 
dependent variable will be the outcome. If the coefficient for MRT or a potential mediator is 
significant in all of these cases, we will proceed. In the final regression, the MRT dummy 
variable will be entered simultaneously with the potential mediator as predictors of the outcome. 
If the coefficient for the potential mediator is significant and the coefficient for the MRT dummy 
variable on the outcome is reduced, we will conclude that mediation is supported and will 
evaluate whether the indirect effect is significant.62 To account for variability in intensity of 
continuing care services, we will test for significant interactions on outcomes between our 
measures of continuing care and a variable for site. 
We will also determine if any significant, direct effects of MRT on (a) overall risk for recidivism, 
and (b) the health-related outcomes, are mediated by specific mechanisms of MRT (i.e., 
improvements in interpersonal functioning and reductions in affiliations with antisocial and 
substance abusing peers). We will conduct GLMM regression models that correspond to a 
hypothesized causal sequence among (1) MRT (vs. UC), (2) the potential mechanisms, and (3) 
one of the outcomes, and control for covariates. Finally, we will conduct regression analyses 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 21 of 30 
 
(controlling for relevant covariates) to examine associations of MRT dose (number of group 
sessions attended; number of steps completed) with patient outcomes at the follow-ups. Based 
on prior work27,47 and the recommendations of VJP Specialists who have previously conducted 
MRT groups with Veterans, we will explore whether completion of 12 sessions is as effective as 
a full dose (24 sessions). 
Adjust for contamination and missing data. To address the possibility of contamination, if we 
learn that MRT-related information was shared with UC participants, the records of those UC 
participants will be flagged, and contamination-adjusted intention-to-treat analyses will be 
calculated84 (i.e., the effect of treatment assignment on outcomes is adjusted by the percentage 
of participants assigned to the UC condition who may have received the treatment). To minimize 
missing data, we will train research assistants on the importance of completing each item while 
respecting the rights of patients to refuse answers. Based on our prior studies, we expect to 
achieve less than 5% missing data on each variable at each assessment, over and above any 
attrition. We will obtain as high a follow-up rate as possible at each assessment. In contrast to 
MH RRTP completion and SUD/mental health continuing care utilization, which will be collected 
primarily via VA administrative data at the 6- and 12-month follow-ups, data on recidivism risk 
and health-related outcomes at the follow-ups will be collected via patient reports, and will 
therefore have more missing data due to expected attrition at those time points. GLMM’s 
strengths are the ability to use all available data, including data on respondents who may not 
have provided data at each assessment. All patients who enter the study will be included in 
GLMM analyses. However, we will also conduct analyses that include only patients who 
attended at least the first MRT session. We will use a model-based multiple imputation 
procedure and will impute missing values using least-squares regression imputation.63 We will 
select a set of measures that are associated with the variable at issue and use it in a series of 
iterated least-squares regression models to generate a predicted value for the variable being 
imputed, and then substitute the missing value with the predicted value.64 
Aim 2: Analytic plan. De-identified audio-files of the staff and patient interviews will be 
transcribed.  The transcription will be performed by a professional medical transcription agency 
specifically chosen for this study.  Drs. Blonigen and Timko will review the transcripts of these 
interviews, and take detailed notes using the structure of the RE-AIM Planning Tool. With 
feedback from project team members, we will create tables to summarize and categorize the 
barriers/facilitators of MRT implementation at the system, provider, and patient levels, and 
include potential solutions and potential-to-leverage columns that contain evidence-based 
implementation tools to be considered for more widespread usage of MRT. These analyses will 
reduce and display the data. In conjunction with the tables, we will identify a small set of themes 
within each domain of the RE-AIM framework that signify triangulated findings (e.g., factors that 
would facilitate and maintain a program’s use of MRT in a way that fits within the clinical and 
administrative infrastructure of the facility). The purpose will be to capture in-depth information 
on patient, provider, and contextual factors that will facilitate or hinder the successful 
implementation of MRT. Such factors will be used to inform post-hoc interpretation of project 
findings and guide development of action plans to be tested in subsequent implementation 
projects. If Aim 1 hypotheses are not supported, we will use this analytic approach to identify 
barriers associated with delivery of MRT during the RCT, and what modifications to MRT could 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 22 of 30 
 
be made to maximize effectiveness. Such information will be shared with our operational 
partners to guide their future efforts to reduce recidivism risk among JIVs. 
5.7 Withdrawal of Subjects 
 
Prospective participants will be told that they may withdraw from the study at any time and 
refrain from answering specific questions; that all information will be confidential and used only 
for the purposes of the research study; and that they may contact the PI (Dr. Blonigen) or a 
research assistant with any questions at any time.  
 
5.8 
Right of Investigator to Terminate Participation 
The investigators may also withdraw the participant from the study and the study intervention 
may be stopped without consent for one or more of the following reasons:  1) Failure to follow 
the instructions of the investigators and/or study staff, 2) Continuation in the study could be 
harmful to the participant, 3) The study is cancelled, 4) Other administrative reasons, and 5) 
Unanticipated circumstances.. 
Any withdrawal from the study on the part of investigators will not affect the standard care that 
the participant is receiving in the Domiciliary Program or any other VA health care to which the 
participant is entitled to. 
6.0 Reporting 
 
Protection against risk. In attempting to contact potential participants (or even those who are 
already enrolled in the study) the research assistant will explain to any other person who they 
reach that s/he is trying to locate the individual regarding a health survey. The project will never 
be described to any non-participant the research assistant may reach as a study of criminal 
recidivism, mental health problems, substance abuse, homelessness, or unemployment, nor will 
we label any individual as a criminal offender, mental health patient, substance abuser, 
homeless, or unemployed. To further preserve confidentiality, we will not include the 
respondent’s name on any interview. Instead, these documents will be given experimentally-
assigned ID numbers. The master list that contains names, contact information, and ID numbers 
will be kept in password- and fire-wall protected computer files that are accessible only to 
project staff, and all data with personal identifiable information will be stored in locked file 
drawers. 
The Intervention Coordinators will be thoroughly trained and closely supervised during the 
period in which they are conducting the MRT groups. The research assistants will also be 
thoroughly trained and closely supervised during the data collection period. For example, initial 
and maintenance training on the Addiction Severity Index (ASI) begins with viewing a four-part 
training DVD that is distributed by the ASI’s developers. Training of the research assistants will 
also entail the trainee observing other staff conducting interviews, being supervised by another 
experienced interviewer while conducting interviews, and receiving feedback. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 23 of 30 
 
All contacts and interviews will be conducted in a sensitive manner that protects the dignity of 
respondents. Intervention Coordinators and research assistants will be prepared for situations in 
which a respondent expresses the need for help for a personal or emotional problem. If a 
respondent verbalizes such a need while they are still under the care of the MH RRTP, the 
research team member will ask if s/he can inform the program staff about the patient’s 
problems. If a respondent verbalizes such a need while they are no longer a resident of the MH 
RRTP, the research team member will ask the participant if s/he would like a referral for 
counseling or treatment. If the respondent wants such information, the research team member 
will provide it. 
In addition to the Intervention Coordinators, the research assistants will be trained and prepared 
for situations in which a participant expresses severe distress (e.g., serious depression with 
suicidal tendencies). Importantly, at the beginning of the study (i.e., during the baseline 
assessment and during the MRT intervention groups), the participants will be residents of the 
MH RRTPs at each site and will be under the close supervision of the mental health and 
medical staff in these programs who can directly address these situations. However, in the 
event the participant expresses suicidal or homicidal ideation or other serious psychiatric or 
medical symptoms during a time when the participant is not a resident of the MH RRTP, the PI 
at all three sites will be notified immediately. At the Palo Alto site, Dr. Blonigen (PI) is a licensed 
clinical psychologist. At the Little Rock site, Dr. Cucciare (Co-Investigator) is a licensed clinical 
psychologist. At the Bedford site, Dr. Smelson (PI) is a licensed clinical psychologist. These 
members of the project team will be available to consult with the other research team members 
and/or speak with the participant if any concerning events arise. At the Palo Alto VA, other 
licensed mental health professional staff (10 additional psychologists at the Center for 
Innovation to Implementation) will act as back-up contacts in the event that Dr. Blonigen and 
project affiliate staff are not available for consultation. At both the Little Rock and Bedford VAs, 
the MH RRTP Directors and up to 2 clinical providers will serve as back-up contacts in the event 
that the site PI and project affiliate staff are not available for consultation. All project staff will 
have been trained on VA’s suicide risk assessment and response guidelines, including the 
capability of directly connecting suicidal participants to the 24-hour VA suicide hotline, as well as 
arranging with local mental health crisis management staff to assess and potentially hospitalize 
the patient. Subsequent to any participant’s expression of severe distress, project staff will make 
all reasonable attempts to re-contact the participant to monitor his/her well-being until the acute 
situation is resolved. 
This project does not include administration of alcohol or other drugs, and is not a human 
laboratory study of alcohol or other drug intake. The PIs will be made aware of all potentially 
negative or concerning participant contacts and will determine when events are serious adverse 
events or non-serious adverse events. Any serious adverse events will be reported to the 
appropriate IRBs within 48 hours. 
7.0 Privacy and Confidentiality 
 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 24 of 30 
 
Patient privacy and confidentiality. Data from patients will be obtained by means of 
interviews and self-report questionnaires administered at three time points (the first of which will 
be conducted in person, the last two either in-person or via phone) for the RCT, and a one-time 
semi-structured interview (conducted in person or via phone) for the formative evaluation. For 
the RCT, data from the VA Corporate Data Warehouse (CDW) will also be extracted to obtain 
patients’ substance use disorder (SUD) and mental health service utilization during the study 
period.  The data extracted from CDW will be stored only on a secure VA VINCI project folder 
allocated to this study by VINCI and maintained by VINCI OI&T personnel. Data from VA staff 
members will be obtained from a one-time semi-structured interview administered either in-
person or via phone. 
All research material will be collected solely for the purposes of the study. All subject data will 
remain confidential after it is collected. All collected data will be stored in a format that is 
identifiable only by an experimentally-assigned ID number rather than with participants’ name or 
any other personal identifiable information.   
In attempting to contact potential participants, or even those who are already enrolled in the 
study, the research assistant will explain to any other person who they reach that s/he is trying 
to locate the individual regarding a health survey. The project will never be described to any 
non-participant the research assistant may reach as a study of criminal recidivism, mental 
health problems, substance abuse, homelessness, or unemployment, nor will we label any 
individual as a criminal offender, mental health patient, substance abuser, homeless, or 
unemployed. To further preserve confidentiality, we will not include the respondent’s name on 
any interview. Instead, these documents will be given experimentally-assigned ID numbers. The 
master list that contains names, contact information, and ID numbers will be kept in password- 
and fire-wall protected computer files that are accessible only to project staff, and all data with 
personal identifiable information will be stored in locked file drawers. 
For any follow-up interviews with incarcerated participants, these will be conducted via phone 
and will not be videotaped or audio-recorded. We will use similar privacy protections for 
incarcerated participants as we have used to ensure the privacy of participants in our past 
studies (e.g., inpatients in shared hospital rooms). Specifically, after asking participants a 
question (which others in the vicinity will not be able to hear), the interviewer will give the 
response options to the participant and ask the participant to only say the number or letter 
corresponding to their answer (e.g., “5” for “extremely”). If the participant believes s/he cannot 
fully answer any particular questions in this environment, then they will not have to answer 
those questions. 
Data from providers will be obtained by means of a one-time semi-structured interview 
(conducted in person or via phone) for the formative evaluation. All provider participants will be 
informed that their decision to participate or not in the interview and their responses to the 
interview itself will not be disclosed to their supervisors or other VA employees or Veterans. To 
ensure this protection, a research staff member will attend MH RRTP staff meetings and 
distribute the information sheet that is included in this Central IRB application.  MH RRTP staff 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 25 of 30 
 
will then be informed that if they are interested in participating, they can contact the number 
listed at the bottom of the information sheet.  
Data Collection: The self-report participant data that is collected from the baseline, 6-month 
follow-up, and 12-month follow-up interviews will be entered and managed using the program, 
IBM Statistical Package for the Social Sciences (SPSS), Version 21. This data will be entered, 
managed, and stored at the coordinating site (VA Palo Alto).Research Assistants at Bedford 
VAMC and Central Arkansas Veterans HCS will scan the completed baseline and the 6- and 12-
month follow-up assessment protocols of study participants and upload the pdfs of the scanned 
copies to a secure shared folder on the VA network that is only accessible by the research staff.  
Designated research assistants at VA Palo Alto will enter data into a password-protected SPSS 
database.  All baseline and 6- and 12-month assessments will be kept in locked file cabinets.  A 
copy of this self-report data will also be stored on the project folder in VINCI.   
Research assistants will receive training in areas of data security, data collection and data entry 
to ensure uniformity.  Access to the SPSS database will be restricted to only those who are 
deemed necessary for project execution.  The servers housing the study database and baseline 
and follow-up assessments will be located at a secure VA facility and housed behind the VA 
firewall on VA-owned and-maintained servers.   
In case of improper use or disclosure of study data, the facility’s ISO and Privacy Officer, and 
the individual’s direct supervisor will be notified immediately per VA Directive and Handbook 
6500. According to the VHA Records Control Schedule, research data will be destroyed 6 years 
after cutoff but may be retained longer if required by other federal regulations.  The cutoff date is 
at the end of the fiscal year after completion of the research project. 
Quality control checks and clinical monitoring procedures will be implemented to ensure that 
data entered into the study database is correct. 
Data and safety monitoring. This project will be overseen by the HSR&D Data and Safety 
Monitoring Board, which reviews multisite interventional studies. This Board provides guidelines 
on plans for monitoring the safety of participants and the accuracy and integrity of the data, and 
reviews participant recruitment and enrollment. We will comply with all Board guidelines and 
requirements.  
As noted above, a number of safeguards are in place to protect the confidentiality of subjects. 
All project personnel will be required to complete mandatory VA trainings related to the use of 
human subject data including (a) Good Clinical Practices and Human Subjects, (b) VA Privacy, 
(c) VA Cyber Security Awareness, and (d) the VA Information Security 201 online training 
courses and regulations for data transportation, storage, and destruction. All data will be stored 
electronically in a restricted access folder and will be stored on VA-issued, supported, and 
password-protected computers. Only approved project personnel will have access to these 
data.  For the current study, we will retain subject contact information and data for future 
research studies. To this end, during the informed consent process and HIPAA authorization we 
will request permission from subjects to retain their contact information and data after the study 
is completed and to re-contact them about participating in future VA research projects. This data 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 26 of 30 
 
will be stored in a to-be-established data repository, which will be set up in accordance with 
VHA Handbook 1200.12.  The IRB of record for VA Palo Alto (Stanford Human Subjects 
Committee) and the VA Palo Alto Research & Development Committee will oversee the to-be-
established data repository. 
In addition to receiving training on data security and privacy issues, the sensitive nature of the 
information being collected will be emphasized with all project staff. Further, all matching of 
participants with their criminal data will be overseen directly by the site PIs to ensure that the 
utmost caution is being taken to protect privacy. It should be reiterated that this study is 
recruiting JIVs from VA MH RRTPs, and is not recruiting Veterans from incarcerated settings. 
However, we plan to conduct follow-up assessments at 6- and 12-months post-baseline, and at 
those time points some participants may be incarcerated.  
8.0 Communication Plan 
As PI, Dr. Blonigen will oversee and ensure the integrity of all aspects of the proposed work. 
Drs. Blonigen and Smelson have a longstanding, productive, and collegial partnership in mental 
health services research projects. As a leadership team, they will oversee all planning of dataset 
construction, analyses, and manuscript preparation, and will ensure that all required approvals 
have been obtained. The leadership team, data analysts, and research assistants will meet on a 
weekly basis to facilitate work flow, quality assurance, and momentum during the project start-
up period and first month of study enrollment. Drs. Blonigen, Smelson, and Cucciare (as Local 
Site Investigators for Palo Alto, Bedford, and Little Rock, respectively) will facilitate and 
supervise the data collection within their respective MH RRTPs and participate fully in scientific 
decision making related to study development, fidelity, and the synthesis and dissemination of 
results.  
After this time period, all-staff phone conferences will occur bi-weekly. These meetings will 
function as check-ins to ensure that the study is being conducted according to the Central IRB-
approved protocol. In the event of more urgent needs, such as Serious Adverse Events or 
Unanticipated Problems, the leadership team will contact the Local Site Investigators directly. 
Throughout the study duration, Drs. Blonigen and Smelson will hold a separate weekly meeting 
with the Project Manager to discuss progress on the specific tasks in the project timeline. Any 
issues raised during these meetings will be emailed to all project team members for feedback 
and included on the agenda for the next all-staff phone conference.  
In the event of improper use or disclosure of PHI, the relevant site’s Information Security Officer 
and Privacy Officer will be notified within one hour of the improper use or disclosure and all local 
policies will be followed.  This event will also be communicated to the Local Site Investigators 
and the Principal Investigator. When a researcher leaves a study team (either by transferring to 
another position within the VA or leaving the VA), their access to these secure folders is 
removed by the Principal Investigator. Local check out policy demands that individuals be 
removed from all research protocols, keys for files and offices are turned in, and electronic 
access to research files is revoked prior to leaving the facility. 
9.0 References 
1 Langan PA, Levin, DJ. Recidivism of prisoners released in 1994. 2002. Retrieved from the 
Bureau of Justice Statistics website: http/bjs.gov/content/pub/pdf/rpr94.pdf 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 27 of 30 
 
2 Mumola CJ. Veterans in prison or jail. 2000. Retrieved from the Bureau of Justice Statistics 
website: http://bjs.gov/content/pub/pdf/vpj.pdf 
3 Andrews DA, Bonta J. The empirical base of PCC and the RNR model of assessment and 
crime prevention through human service. The psychology of criminal conduct. 5th ed. Anderson, 
New Providence, NJ: Anderson; 2010, pp. 45-78. 
4 Little GL, Robinson KD. Moral reconation therapy: A systematic step-by-step treatment system 
for treatment resistant clients. Psychol Rep, 1988; 62, 135-151. 
5 Little GL. Meta-analysis of moral reconation therapy recidivism results from probation and 
parole implementations. Cogn Behav Treat Rev, 2005; 14, 14-16. 
6 Aos S, et al. Evidence-based adult corrections programs. Retrieved from the Washington State 
Institute for Public Policy website: http://www.wsipp.wa.gov/rptfiles/06-01-1201.pdf 
7 Ferguson LM, Wormith JS. A meta-analysis of moral reconation therapy. Int J Offender Ther 
Comp Criminol, 2013; 57, 1076-1106. 
8 Wilson DB, Bouffard LA, Mackenzie DL. A quantitative review of structured, group-oriented, 
cognitivebehavioral programs for offenders. Crim Justice Behav, 2005; 32, 172-204. 
9 Little GL, Robinson KD. Winning the invisible war. Memphis: Eagle Wing Books; 2013. 
10 Curran GM, et al. Effectiveness-implementation hybrid designs. Med Care, 2012; 50, 217-226. 
11 Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion 
interventions: The RE-AIM framework. A J Public Health, 1999; 89, 1322-1327. 
12 Noonan ME, Mumola CJ. Veterans in state and federal prison, 2004. 2007. Retrieved from the 
Bureau of Justice Statistics website: http://bjs.gov/content/pub/pdf/vsfp04.pdf 
13 Glaze LE. Correctional population in the United States, 2010. 2011. Retrieved from the 
Bureau of Justice Statistics website: http://www.bjs.gov/content/pub/pdf/cpus10.pdf 
14 Tsai J, et al. Risk of incarceration and other characteristics of Iraq and Afghanistan era 
veterans in state and federal prisons. Psychiatr Serv, 2013; 64; 36-43. 
15 Erickson SK, Rosenheck RA, Trestman RL, Ford JD, Desai RA. Risk of incarceration between 
cohorts of veterans with and without mental illness discharged from inpatient units. Psychiatr 
Serv, 2008; 59, 178-183. 
16 Greenberg GA, Rosenheck RA. Mental health and other risk factors for jail incarceration 
among male veterans. Psychiatr Q, 2009; 80, 41-53. 
17 Landenberger NA, Lipsey MW. The positive effects of cognitive-behavioral programs for 
offenders: A meta-analysis of factors associated with effective treatment. J Exp Criminol, 2005; 
1, 451-476. 
18 Milkman H, Wanberg K. Cognitive behavioral treatment: A review and discussion for 
corrections professionals. 2007. Retrieved from the NIC website: 
http://static.nicic.gov/Library/021657.pdf 
19 Andrews DA, et al. The recent past and near future of risk and/or need assessment. Crime 
Delinq, 2006; 52, 7-27. 
20 Black DW, et al. Incarceration and veterans of the first Gulf War. Mil Med, 2005; 170, 612-
618. 
21 Bovasso GB, et al. The prediction of violent and nonviolent criminal behavior in a methadone 
maintenance population. J Pers Dis, 2002; 16, 360-373. 
22 Kasarabada ND, et al. Cocaine, crime, family history of deviance: are psychosocial correlates 
related to these phenomena in male cocaine abusers? Subst Abuse, 2000; 21, 67-78. 
23 Blodgett JC, et al. A structured evidence review to identify treatment needs of justice-involved 
Veterans and associated psychological interventions. Veterans Health Administration; 2013. 
24 Taber KH, Hurley RA. OEF/OIF deployment-related traumatic brain injury. PTSD Res Q, 
2010; 21, 1-8. 
25 Anderson JL. Overview of the Illinois DOC high-risk parolee re-entry program and 3-year 
recidivism outcomes of program participants. Cogn Behav Treat Rev, 2002; 11, 4-6. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 28 of 30 
 
26 Boston C. Changing offenders' behavior: Evaluating moral reconation therapy in the better 
people program. 2001. Retrieved from the Better People website: 
http://www.betterpeople.org/docs/evaluation.pdf 
27 Burnette KD, et al. Male juvenile offenders participating in MRT within a therapeutic 
community program continue to show positive results. Cogn Behav Treat Rev, 2004; 13, 3-5. 
28 Lindholm C. Preliminary outcomes with moral reconation therapy: Northeast Texas Restitution 
Center, Maud, TX. Cogn Behav Treat Rev, 1998; 7, 16. 
29 Little GL. Meta-analysis of MRT recidivism research on post-incarceration adult felony 
offenders. Cogn Behav Treat Rev, 2001; 10, 4-6. 
30 Little G, et al. Successful ten-year outcome data on MRT-treated felony offenders: Treated 
offenders show significantly lower reincarceration in each year. Cogn Behav Treat Rev, 1999; 8, 
1-3. 
31 McCracken L, et al. Juvenile dwi/drug court Albuquerque, NM. Cogn Behav Treat Rev, 2003; 
12, 8-9. 
32 Little GL, et al. An MRT based cognitive-behavioral treatment for first-time dui offenders. Cogn 
Behav Treat Rev, 2010; 19, 1-5. 
33 Sherman LW, et al. Preventing crime: What works, what doesn't, what's promising. 1998. 
Retrieved from the National Criminal Justice Reference Service website: 
https://www.ncjrs.gov/pdffiles/171676.PDF 
34 Farrington DP. Methodological quality standards for evaluation research. Ann Am Acad Pol 
Soc Sci, 2003; 587, 49-68. 
35 Brame R, et al. Moral Reconation Therapy and problem behavior in the Oklahoma department 
of corrections. J Oklahoma Crim Just Res Consort, 1996; 3, 63-84. 
36 Burnett W. Treating post-incarcerated offenders with moral reconation therapy: A one-year 
recidivism study. Cogn Behav Treat Rev, 1997; 6, 2. 
37 Little GL, Robinson KD. Treating drunk drivers with moral recognition therapy: A one-year 
recidivism report. Psychol Rep, 1989; 64, 960-962. 
38 Little GL, Robinson KD, Burnette KD. Treating drug offenders with moral reconation therapy: 
A three-year recidivism report. Psychol Rep, 1991; 69, 1151-1154. 
39 Fuller D. 16th judicial district of Tennessee drug court program outcome evaluation. 2003. 
Retrieved from Rutherford County Tennessee Drug Court: 
rutherfordcountytn.gov/drug_court/docs/2003outcomereport.pdf 
40 Burnette K, et al. Recidivism of MRT-treated male offenders in a prison-based therapeutic 
community. Cogn Behav Treat Rev, 2005; 14, 10. 
41 Gilreath L. First wings of freedom program: Results and observations. Cog Behav Treat Rev, 
1995; 4, 14-15. 
42 Clark S, et al. 10NC1 Homeless Program VJO strategic plan, FY 2012-2016. Washington, 
DC: Department of Veterans Affairs; 2010. 
43 Smelson DA, et al. A brief treatment engagement intervention for individuals with co-occurring 
mental illness and substance use disorders: Results of a randomized clinical trial. Comm Mental 
Health J, 2012; 48, 127-132. 
44 Smelson DA, et al. A wraparound treatment engagement intervention for homeless veterans 
with cooccuring disorders. Psychol Serv, 2013; 10, 161-167. 
45 Timko C, DeBenedetti A. A randomized controlled trial of intensive referral to 12-step self-help 
groups: One year outcomes. Drug Alcohol Depend, 2007; 90, 270-279. 
46 Timko C, et al. Intensive referral to 12-step dual-focused mutual help groups. Drug Alcohol 
Depend, 2011; 118, 194-201. 
47 Krueger S. Three-year recidivism of MRT-treated offenders in a county jail. Cogn Behav Treat 
Rev, 1995; 4, 12. 
48 McLellan AT, et al. The addiction severity index at 25: Origins, contributions and transitions. 
Am J Addict, 2006; 15, 113-124. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 29 of 30 
 
49 Tonigan JS, Connors GJ, Miller WR. Alcoholics Anonymous Involvement (AAI) scale: 
Reliability and norms. Psychol Addict Behav, 1996; 10, 75-80. 
50 Neale J, Robertson M. Comparisons of self-report data and oral fluid testing in detecting drug 
use amongst new treatment clients. Drug Alcohol Depend, 2003; 71, 57-64. 
51 Cacciola JS, et al. Development and initial evaluation of the Brief Addiction Monitor (BAM). J 
Subst Abuse Treat, 2013; 44, 256-263. 
52 Whiteside SP, Lynam DR. The five factor model and impulsivity: Using a structural model of 
personality to understand impulsivity. Pers Individ Dif, 2001; 30, 669-689. 
53 Lynam DR, Miller JD. Personality pathways to impulsive behavior and their relations to 
deviance: Results from three samples. J Quant Criminol, 2007; 20, 319–341. 
54 Barkham M, Hardy GE, Startup M. The IIP-32: A short version of the inventory of 
interpersonal problems. Br J Clin Psychol, 1996; 35, 21-35. 
55 Moriarty N, et al. Deficits in emotional intelligence underlying adolescent sex offending. J 
Adolesc, 2001; 24, 743-751. 
56 Fureman B, Parikh G, Bragg A. ASI 5th edition: A guide to training and supervising ASI 
interviews based on the past ten years. Philadelphia, PA: Penn-VA Center for Studies of 
Addiction; 1990. 
57 Sobell LC, Brown J, Leo GI. The reliability of the alcohol timeline followback when 
administered by telephone and by computer. Drug Alcohol Depend, 1996; 42, 49-54. 
58 Raudenbush SW, Bryk AS. Hierarchical linear models: Applications and data analysis 
methods. Thousand Oaks, CA: Sage; 2001. 
59 Staines GL, Cleland CM, Blankertz L. Counselor confounds in evaluations of vocational 
rehabilitation methods in substance dependence treatment. Eval Rev, 2006; 30, 139-170. 
60 Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological 
research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol, 1986; 51, 
1173-1182. 
61 Kraemer HC, et al. How do risk factors work together? Mediators, moderators, and 
independent, overlapping, and proxy risk factors. Am J Psychiatry, 2001; 158, 848-856. 
62 Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple 
mediation models. Behav Res Methods Instrum Comput, 2004; 36, 717-731. 
63 Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods, 
2002; 7, 147-177. 
64 Van Buuren S, Oudshoorn CGM. Multivariate imputation by chained equations. Leiden, 
Netherlands: TNO Prevention and Health; 2000. 
65 Forman J, et al. RE-AIM Plus: Expanding the RE-AIM framework for real-time program 
evaluation. Ann Arbor, MI: VA CCMR; 2010. 
66 Holmbeck GN. Post-hoc probing of significant moderational and mediational effects in studies 
of pediatric populations. J Pediat Psychol, 2002; 27: 87-96. 
67 Selya AS, et al. A practical guide to calculating Cohen’s f2, a measure of local effect size, from 
PROC MIXED. Front Psychol, 2012; 3, 1. 
68 Fontaine J. Examining Housing as a Pathway to Successful Reentry. The Urban Institute; 
2013. 
69 Fontaine J, Biess J. Housing as a platform for formerly incarcerated persons. The Urban 
Institute; 2012. 
70 Marshall AD, et al. Intimate partner violence among military veterans and active duty 
servicemen. Clin Psychol Rev, 2005; 25, 862. 
71 Elbogen EB, et al. Improving risk assessment of violence among military veterans. Clin 
Psychol Rev, 2010; 30, 595. 
72 Timko C, et al. Treatments for recidivism risk among justice-involved veterans. J Offender 
Rehabil, 2014; 53, 620-640. 

[1/2/19]  
Protocol – Blonigen –1/2/19 
Page 30 of 30 
 
73 Blonigen DM, et al. Alcoholics Anonymous attendance, decreases in impulsivity, and drinking 
and psychosocial outcomes over 16 years. Addict, 2011; 106, 2167. 
74 Caton CLM, et al. Risk factors for long-term homelessness: Findings from a longitudinal study 
of first-time homeless single adults. Am J Public Health, 2005; 95, 1753. 
75 Olver ME, et al. Thirty years of research on the level of service scales. Psychol Assess, 2014; 
26, 156.  
76 Pinals DA. Veterans and the justice system. J Am Acad Psychiatry Law, 2010; 38, 163. 
77 Rosenthal L, McGuire J. Incarcerated veterans. In L. Gideon (Ed.), Special needs offenders in 
correctional institutions (pp. 345-376). Thousand Oaks, CA: SAGE Publications; 2013. 
78 Halvorson A. Understanding the military. Rockville, MD: Center for Substance Abuse 
Treatment; 2010. 
79 Roberts BW, Caspi A, Moffitt TE. Work experiences and personality development in young 
adulthood. J Pers Soc Psychol, 2003; 84, 582. 
80 Motiuk MS, Motiuk LL, Bonta J. A comparison between self-report and interview based 
inventories in offender classification. Crim Justice Behav, 1992; 19, 143. 
81 Kroner DG, Mills JF, Morgan RD. Underreporting of crime-related content and the prediction 
of criminal recidivism among violent offenders. Psychol Serv, 2007; 4, 85. 
82 Faul F, et al. Statistical power analyses using G*Power 3.1: Tests for correlation and 
regression analyses. Behav Res Methods, 2009; 41, 1149. 
83 Walters GD. Risk-appraisal versus self-report in the prediction of criminal justice outcomes. 
Crim Justice Behav, 2006; 33, 279. 
84 Sussman. An IV for the RCT: Using instrumental variables to adjust for treatment 
contamination in randomized controlled trials. BMJ, 2010; 340. 
85 Forrest W, et al. Individual differences in the concordance of self-reports and official records. 
Crim Behav Ment Health, 2014; 24, 305-315. 
86 Pocock S. Protocol deviations. In S. Pocock (Ed.), Clinical trials (pp. 176-186). New York: 
John Wiley; 1983. 
87 Lash S, et al. Social reinforcement of substance abuse treatment aftercare participation: 
Impact on outcome. Addict Behav, 2004; 29, 337-342. 
88 McKay J. Continuing care research. J Subst Abuse Treat, 2009; 36, 131-145.