MRT: Justice-Involved Veterans and Moral Reconation Therapy

• Sponsor: VA Office of Research and Development (U.S. Fed)
• Overall Status: Completed
• CT.gov ID: NCT02524171
• Collaborator: (none)
• Enrollment: 344
• Locations: 3
• Arms: 2
• Actual Duration (Months): 59.8
• Patients Per Site: 114.7
• Patients Per Site Per Month: 1.9

Study Details

Study Description

Brief Summary

The purpose of this study is to determine whether Moral Reconation Therapy (MRT) is effective for reducing risk of criminal recidivism and improving other health-related outcomes (substance use, mental health, housing, and employment problems) among justice-involved Veterans entering residential mental health treatment programs in the Department of Veterans Affairs (VA).

Condition or Disease	Intervention/Treatment	Phase
Antisocial Personality Disorder; Substance Use Disorder	Behavioral: Moral Reconation Therapy (MRT)	N/A

Detailed Description

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 (improvements in interpersonal functioning and impulse control) 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 (e.g., prevalence of traumatic brain injuries; interpersonal problems) 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.

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 Randomized Controlled Trial (RCT) (Palo Alto, Little Rock, and Bedford VAs) and conduct a formative evaluation to facilitate future implementation of MRT in VA.

Study Design

• Study Type: Interventional
• Actual Enrollment: 344 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Single (Outcomes Assessor)
• Masking Description: Research Assistants conducting the 6- and 12- month outcome assessments are blinded to condition assignment.
• Primary Purpose: Treatment
• Official Title: Improving Treatment Engagement and Outcomes Among Justice-involved Veterans
• Actual Study Start Date: Apr 4, 2016
• Actual Primary Completion Date: Sep 30, 2020
• Actual Study Completion Date: Mar 30, 2021

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Moral Reconation Therapy (MRT) MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Behavioral: Moral Reconation Therapy (MRT); MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.; Other Names: MRT
No Intervention: Usual Care (UC) Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.

Outcome Measures

Primary Outcome Measures

1. Risk for Criminal Recidivism (Criminal Thinking) [6 months (post-baseline)]

   The Psychological Inventory of Criminal Thinking Styles (56 items) was administered to assess criminal thinking. The measure includes scales of Mollification, Cutoff, Entitlement, Power Orientation, Super-optimism, Cognitive Indolence, and Discontinuity . Scores on these scales were summed to create a General Criminal Thinking score, which has been validated as an overall index of recidivism risk. Higher scores equate to more criminal thinking. Scores were converted to a T-score metric (M=50, SD=10), calculated in reference to norms from samples of incarcerated offenders.

2. Risk for Criminal Recidivism (Criminal Thinking) [12 months (post-baseline)]

   The Psychological Inventory of Criminal Thinking Styles (56 items) was administered to assess criminal thinking. The measure includes scales of Mollification, Cutoff, Entitlement, Power Orientation, Super-optimism, Cognitive Indolence, and Discontinuity . Scores on these scales were summed to create a General Criminal Thinking score, which has been validated as an overall index of recidivism risk. Higher scores equate to more criminal thinking. Scores were converted to a T-score metric (M=50, SD=10), calculated in reference to norms from samples of incarcerated offenders.

Secondary Outcome Measures

1. Alcohol Use [6 months (post-baseline)]

   The quantity and frequency of patients' self-reported alcohol use in the past 6 months, measured with the Timeline Follow-Back interview that was administered at the 6-month follow-up interview.

2. Drug Use [6 months (post-baseline)]

   The quantity and frequency of patients' self-reported drug use in the past 6 months, measured with the Timeline Follow-Back interview. It was administered at each time point to calculate for the past 6 months total number of days using any drugs (marijuana, cocaine, amphetamines, heroin, other opiates, benzodiazepines, barbiturates, inhalants, or hallucinogens).

3. Criminal Associates [6 months (post-baseline)]

   Scale A of the Measures of Criminal Attitudes and Associates (MCAA; Mills, Kroner, & Forth, 2002) was administered at each interview to quantify participants' associations with criminal peers, a strong predictor of criminal recidivism (Mills, Kroner, & Hemmati, 2004). Participants were asked to consider the four adults (excluding family, co-workers, or other residents in treatment) with whom they spend the most free-time. A count variable was created by summing the number of friends for which the participant answered yes to any of the questions of criminal involvement (possible range=0-4, where a higher score indicates a worse outcome)

4. Employment Problem Severity [6 months (post-baseline)]

   The Employment module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.

5. Alcohol Use Problem Severity. [6 months (post-baseline)]

   The Alcohol module of the ASI was administered at each time point to assess problem severity in this domain, using composite score indices (ranging from 0 to 1); higher scores indicate greater problem severity. ASI composite scores such as this have long been used to provide internally-consistent evaluations of a patient in a particular problem area (Grahn & Padyab, 2020).

6. Legal Problem Severity [6 months (post-baseline)]

   The Legal Status module of the Addiction Severity Index (ASI; McLellan et al., 2006) was administered at each interview to assess legal problem severity. The latter is based on a composite index derived from five items: Are you presently awaiting charges, trial, or sentence? How many days in the past 30 have you engaged in illegal activities for profit? How serious do you feel your present legal problems are? (0=Not at all, 4=Extremely) How important to you now is counseling or referral for these legal problems? (0=Not at all, 4=Extremely) How much money did you receive from illegal sources in the past 30 days? These items were standardized and aggregated and yield scores ranging from 0 to 1; higher scores indicate greater problem severity of legal problems.

7. Family/Social Problems [6 months (post-baseline)]

   The Family/Social module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.

8. Alcohol Use [12 months (post-baseline)]

   The quantity and frequency of patients' self-reported alcohol use in the past 6 months, measured with the Timeline Follow-Back interview that was administered at the 12-month follow-up interview.

9. Drug Use [12 months (post-baseline)]

   The quantity and frequency of patients' self-reported drug use in the past 6 months, measured with the Timeline Follow-Back interview. It was administered at each time point to calculate for the past 6 months total number of days using any drugs (marijuana, cocaine, amphetamines, heroin, other opiates, benzodiazepines, barbiturates, inhalants, or hallucinogens).

10. Criminal Associates [12 months (post-baseline)]

    Scale A of the Measures of Criminal Attitudes and Associates (MCAA; Mills, Kroner, & Forth, 2002) was administered at each interview to quantify participants' associations with criminal peers, a strong predictor of criminal recidivism (Mills, Kroner, & Hemmati, 2004). Participants were asked to consider the four adults (excluding family, co-workers, or other residents in treatment) with whom they spend the most free-time. A count variable was created by summing the number of friends for which the participant answered yes to any of the questions of criminal involvement (possible range=0-4, where a higher score indicates a worse outcome)

11. Employment Problem Severity [12 months (post-baseline)]

    The Employment module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.

12. Alcohol Use Problem Severity. [12 months (post-baseline)]

    The Alcohol module of the ASI was administered at each time point to assess problem severity in this domain, using composite score indices (ranging from 0 to 1); higher scores indicate greater problem severity. ASI composite scores such as this have long been used to provide internally-consistent evaluations of a patient in a particular problem area (Grahn & Padyab, 2020).

13. Legal Problem Severity [12 months (post-baseline)]

    The Legal Status module of the Addiction Severity Index (ASI; McLellan et al., 2006) was administered at each interview to assess legal problem severity. The latter is based on a composite index derived from five items: Are you presently awaiting charges, trial, or sentence? How many days in the past 30 have you engaged in illegal activities for profit? How serious do you feel your present legal problems are? (0=Not at all, 4=Extremely) How important to you now is counseling or referral for these legal problems? (0=Not at all, 4=Extremely) How much money did you receive from illegal sources in the past 30 days? These items were standardized and aggregated and yield scores ranging from 0 to 1; higher scores indicate greater problem severity of legal problems.

14. Family/Social Problems [12 months (post-baseline)]

    The Family/Social module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.

Eligibility Criteria

Criteria

• Ages Eligible for Study: N/A and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion 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

Exclusion Criteria:

• The only exclusion criterion is being too cognitively impaired to understand the informed consent process and other study procedures.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR	North Little Rock	Arkansas	United States	72114-1706
2	VA Palo Alto Health Care System, Palo Alto, CA	Palo Alto	California	United States	94304-1290
3	Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA	Bedford	Massachusetts	United States	01730

Sponsors and Collaborators

• VA Office of Research and Development

Investigators

• Principal Investigator: Daniel M. Blonigen, PhD MA, VA Palo Alto Health Care System, Palo Alto, CA

Study Documents (Full-Text)

• Study Protocol and Statistical Analysis Plan - Jan 2, 2019
• Informed Consent Form - Sep 16, 2016

More Information

Publications

None provided.

• Responsible Party: VA Office of Research and Development
• ClinicalTrials.gov Identifier: NCT02524171
• Other Study ID Numbers: IIR 14-081
• First Posted: Aug 14, 2015
• Last Update Posted: Jan 10, 2022
• Last Verified: Dec 1, 2021

• Individual Participant Data (IPD) Sharing Statement: No
• Plan to Share IPD: No
• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No
• Product Manufactured in and Exported from the U.S.: No
• Keywords provided by VA Office of Research and Development: crime; mental health; substance abuse; homelessness; Veterans
• Additional relevant MeSH terms: Disease; Substance-Related Disorders; Personality Disorders; Antisocial Personality Disorder

Study Results

Participant Flow

Recruitment Details	Recruitment began on April 4, 2016 from 3 VA Mental Health Residential Rehabilitation Treatment Program (MH RRTP) at Bedford, MA, Little Rock, AR, and Palo Alto, CA. Recruitment officially closed on July 31, 2018.
Pre-assignment Detail	A total of 344 participants were enrolled across the 3 sites but only 341 were randomized to either the intervention group or control group. Three participants decided to withdraw from the study for various reasons such as declining to finish the baseline interview or deciding that he/she did not want to participate.

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Period Title: 6-month Follow-up
STARTED	172	169
COMPLETED	119	124
NOT COMPLETED	53	45
Period Title: 6-month Follow-up
STARTED	172	169
COMPLETED	127	128
NOT COMPLETED	45	41

Baseline Characteristics

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)	Total
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.	Total of all reporting groups
Overall Participants	172	169	341
Age (Count of Participants)
<=18 years	0 0%	0 0%	0 0%
Between 18 and 65 years	166 96.5%	163 96.4%	329 96.5%
>=65 years	6 3.5%	6 3.6%	12 3.5%
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	45.83 (12.191)	46.60 (12.169)	46.21 (12.168)
Sex: Female, Male (Count of Participants)
Female	8 4.7%	8 4.7%	16 4.7%
Male	164 95.3%	161 95.3%	325 95.3%
Race/Ethnicity, Customized (Count of Participants)
White	97 56.4%	100 59.2%	197 57.8%
Black or African American	45 26.2%	52 30.8%	97 28.4%
American Indian/Alaska Native	4 2.3%	2 1.2%	6 1.8%
Asian/Pacific Islander	4 2.3%	2 1.2%	6 1.8%
Hispanic or Latino/a, White	10 5.8%	6 3.6%	16 4.7%
Other	12 7%	7 4.1%	19 5.6%
Controlled environment (Count of Participants)
No	14 8.1%	10 5.9%	24 7%
Jail	17 9.9%	10 5.9%	27 7.9%
Alcohol or drug treatment	130 75.6%	135 79.9%	265 77.7%
Medical treatment	2 1.2%	6 3.6%	8 2.3%
Psychiatric treatment	6 3.5%	6 3.6%	12 3.5%
Other	3 1.7%	2 1.2%	5 1.5%
Sites (U.S.) (Count of Participants)
Pacific	56 32.6%	55 32.5%	111 32.6%
Continental	55 32%	55 32.5%	110 32.3%
Northeast	61 35.5%	59 34.9%	120 35.2%
Days in the residential program (Days) [Median (Standard Deviation) ]
Median (Standard Deviation) [Days]	91.20 (96.035)	92.55 (100.326)	91.868 (98.183)

Outcome Measures

1. Primary Outcome

Title	Risk for Criminal Recidivism (Criminal Thinking)
Description	The Psychological Inventory of Criminal Thinking Styles (56 items) was administered to assess criminal thinking. The measure includes scales of Mollification, Cutoff, Entitlement, Power Orientation, Super-optimism, Cognitive Indolence, and Discontinuity . Scores on these scales were summed to create a General Criminal Thinking score, which has been validated as an overall index of recidivism risk. Higher scores equate to more criminal thinking. Scores were converted to a T-score metric (M=50, SD=10), calculated in reference to norms from samples of incarcerated offenders.
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	53.66	53.30

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	-0.10
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	-0.88
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

2. Secondary Outcome

Title	Alcohol Use
Description	The quantity and frequency of patients' self-reported alcohol use in the past 6 months, measured with the Timeline Follow-Back interview that was administered at the 6-month follow-up interview.
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [percentage of days abstinent (past 6 mo)]	94	95

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.06
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.02
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

3. Secondary Outcome

Title	Drug Use
Description	The quantity and frequency of patients' self-reported drug use in the past 6 months, measured with the Timeline Follow-Back interview. It was administered at each time point to calculate for the past 6 months total number of days using any drugs (marijuana, cocaine, amphetamines, heroin, other opiates, benzodiazepines, barbiturates, inhalants, or hallucinogens).
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [Days (in past 6 months)]	23.07	15.01

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	10.98
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	14.64
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

4. Secondary Outcome

Title	Criminal Associates
Description	Scale A of the Measures of Criminal Attitudes and Associates (MCAA; Mills, Kroner, & Forth, 2002) was administered at each interview to quantify participants' associations with criminal peers, a strong predictor of criminal recidivism (Mills, Kroner, & Hemmati, 2004). Participants were asked to consider the four adults (excluding family, co-workers, or other residents in treatment) with whom they spend the most free-time. A count variable was created by summing the number of friends for which the participant answered yes to any of the questions of criminal involvement (possible range=0-4, where a higher score indicates a worse outcome)
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [friends with criminal involvement]	0.43	0.28

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	1.45
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	1.22
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

5. Secondary Outcome

Title	Employment Problem Severity
Description	The Employment module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.58	0.61

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.04
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63).
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.02
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

6. Secondary Outcome

Title	Alcohol Use Problem Severity.
Description	The Alcohol module of the ASI was administered at each time point to assess problem severity in this domain, using composite score indices (ranging from 0 to 1); higher scores indicate greater problem severity. ASI composite scores such as this have long been used to provide internally-consistent evaluations of a patient in a particular problem area (Grahn & Padyab, 2020).
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.09	0.06

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6mo.(Beta value)
	Estimated Value	0.04
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.02
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

7. Secondary Outcome

Title	Legal Problem Severity
Description	The Legal Status module of the Addiction Severity Index (ASI; McLellan et al., 2006) was administered at each interview to assess legal problem severity. The latter is based on a composite index derived from five items: Are you presently awaiting charges, trial, or sentence? How many days in the past 30 have you engaged in illegal activities for profit? How serious do you feel your present legal problems are? (0=Not at all, 4=Extremely) How important to you now is counseling or referral for these legal problems? (0=Not at all, 4=Extremely) How much money did you receive from illegal sources in the past 30 days? These items were standardized and aggregated and yield scores ranging from 0 to 1; higher scores indicate greater problem severity of legal problems.
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.14	0.13

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.02
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	-0.08
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

8. Secondary Outcome

Title	Family/Social Problems
Description	The Family/Social module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.
Time Frame	6 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.1	0.1

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.06
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Time x Condition at 6 mo.(Beta value)
	Estimated Value	0.06
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

9. Primary Outcome

Title	Risk for Criminal Recidivism (Criminal Thinking)
Description	The Psychological Inventory of Criminal Thinking Styles (56 items) was administered to assess criminal thinking. The measure includes scales of Mollification, Cutoff, Entitlement, Power Orientation, Super-optimism, Cognitive Indolence, and Discontinuity . Scores on these scales were summed to create a General Criminal Thinking score, which has been validated as an overall index of recidivism risk. Higher scores equate to more criminal thinking. Scores were converted to a T-score metric (M=50, SD=10), calculated in reference to norms from samples of incarcerated offenders.
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	50.96	49.80

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta
	Estimated Value	0.69
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	-0.89
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

10. Secondary Outcome

Title	Alcohol Use
Description	The quantity and frequency of patients' self-reported alcohol use in the past 6 months, measured with the Timeline Follow-Back interview that was administered at the 12-month follow-up interview.
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [percentage of days abstinent (past 6 mo)]	94	94

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	0.07
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63)
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	0.01
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

11. Secondary Outcome

Title	Drug Use
Description	The quantity and frequency of patients' self-reported drug use in the past 6 months, measured with the Timeline Follow-Back interview. It was administered at each time point to calculate for the past 6 months total number of days using any drugs (marijuana, cocaine, amphetamines, heroin, other opiates, benzodiazepines, barbiturates, inhalants, or hallucinogens).
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [Days (in past 6 months)]	18.63	15.03

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	6.53
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	5.68
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

12. Secondary Outcome

Title	Criminal Associates
Description	Scale A of the Measures of Criminal Attitudes and Associates (MCAA; Mills, Kroner, & Forth, 2002) was administered at each interview to quantify participants' associations with criminal peers, a strong predictor of criminal recidivism (Mills, Kroner, & Hemmati, 2004). Participants were asked to consider the four adults (excluding family, co-workers, or other residents in treatment) with whom they spend the most free-time. A count variable was created by summing the number of friends for which the participant answered yes to any of the questions of criminal involvement (possible range=0-4, where a higher score indicates a worse outcome)
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [friends with criminal involvement]	0.37	0.43

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	0.83
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63).
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.01
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta v
	Estimated Value	0.46
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

13. Secondary Outcome

Title	Employment Problem Severity
Description	The Employment module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.48	0.53

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)
	Estimated Value	0.02
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63).
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)
	Estimated Value	-0.08
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

14. Secondary Outcome

Title	Alcohol Use Problem Severity.
Description	The Alcohol module of the ASI was administered at each time point to assess problem severity in this domain, using composite score indices (ranging from 0 to 1); higher scores indicate greater problem severity. ASI composite scores such as this have long been used to provide internally-consistent evaluations of a patient in a particular problem area (Grahn & Padyab, 2020).
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.04	0.06

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)]
	Estimated Value	-0.03
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63).
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)]
	Estimated Value	-0.07
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

15. Secondary Outcome

Title	Legal Problem Severity
Description	The Legal Status module of the Addiction Severity Index (ASI; McLellan et al., 2006) was administered at each interview to assess legal problem severity. The latter is based on a composite index derived from five items: Are you presently awaiting charges, trial, or sentence? How many days in the past 30 have you engaged in illegal activities for profit? How serious do you feel your present legal problems are? (0=Not at all, 4=Extremely) How important to you now is counseling or referral for these legal problems? (0=Not at all, 4=Extremely) How much money did you receive from illegal sources in the past 30 days? These items were standardized and aggregated and yield scores ranging from 0 to 1; higher scores indicate greater problem severity of legal problems.
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.09	0.09

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)]
	Estimated Value	0.01
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63).
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)]
	Estimated Value	-0.08
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

16. Secondary Outcome

Title	Family/Social Problems
Description	The Family/Social module of the ASI was administered at each timepoint to assess problem severity in this domain, using composite score indices (range 0 to 1); higher scores indicate greater problem severity.
Time Frame	12 months (post-baseline)

Outcome Measure Data

Analysis Population Description

Intent to treat population (all participants assigned to MRT or UC) analyzed using mixed-effects models. Effectiveness was measured by the time x condition interaction term (UC as the reference group).

Arm/Group Title	Moral Reconation Therapy (MRT)	Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.	Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
Measure Participants	172	169
Mean (95% Confidence Interval) [score on a scale]	0.19	0.11

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.05
	Comments	The threshold for statistical significance was p = 0.05
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)]
	Estimated Value	0.07
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Statistical Analysis 2

Statistical Analysis Overview	Comparison Group Selection	Moral Reconation Therapy (MRT), Usual Care (UC)
	Comments	Per protocol analysis, which included all UC participants (n=169) and only those in the MRT condition who had received the minimum recommended dose of the intervention - i.e., Step 3 or higher of MRT (n=63).
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	>0.05
	Comments	The threshold for statistical significance was p = 0.05.
	Method	Mixed Models Analysis
	Comments	Models adjusted for covariates (yielded estimated mean values of the outcome) and non-response weights based on completion of follow-up interviews.
Method of Estimation	Estimation Parameter	Other[Time x Condition at 12 mo.(Beta)]
	Estimated Value	0.08
	Confidence Interval	(2-Sided) %; to
	Parameter Dispersion	Type: Value:
	Estimation Comments

Adverse Events

Time Frame	Adverse event data was collected in the 12 months post-baseline for each participant.
Arm/Group Title	Moral Reconation Therapy (MRT)		Usual Care (UC)
Arm/Group Description	MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program. Moral Reconation Therapy (MRT): MRT is a group-based cognitive-behavioral intervention to restructure antisocial thinking. Patients will receive two groups per week of this intervention for approximately 12 weeks, in addition to the usual care they receive in the mental health residential rehabilitation treatment program.		Usual care provided by the mental health residential rehabilitation treatment programs, which patients in both groups are in.
All Cause Mortality
	Moral Reconation Therapy (MRT)		Usual Care (UC)
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	7/172 (4.1%)		12/169 (7.1%)
Serious Adverse Events
	Moral Reconation Therapy (MRT)		Usual Care (UC)
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	2/172 (1.2%)		4/169 (2.4%)
Social circumstances
Death	2/172 (1.2%)	2	4/169 (2.4%)	4
Other (Not Including Serious) Adverse Events
	Moral Reconation Therapy (MRT)		Usual Care (UC)
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/172 (0%)		0/169 (0%)

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

All Principal Investigators ARE employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.