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Alcohol and drug use have consistently been found to be related to a variety of criminal behaviours including property crimes and crimes against persons, (Chaiken & Chaiken, 1982, 1990, Lightfoot & Hodgins, 1988). This relationship holds true whether one studies populations of known substance abusers (Ball, Shaeffer, & Nurco, 1983; Inciardi, 1979, 1981), criminal justice populations (Barton, 1980; 1982; Innes, 1988), and in general population surveys (Robins & Regier, 1991). This relationship also holds true in both adult and adolescent offenders (Elliott & Hunizinga, 1984; Elliott, Hunizinga, & Ageton, 1985). Substance use is also related to poor halfway house adjustment (Moczydlowski, 1980) and parole failure (National Coucil on Crime and Delinquency (NCCD), 1972). Although recent research has indicated that the relationship between substance use and crime is more complex than originally assumed (Bureau of Justice Statistics, 1990), treatment and other interventions aimed at reducing or eliminating offender substance use are potentially effective tools in reducing recidivism.
The primary goal of this chapter is to review the substance abuse treatment literature conducted from 1980 to the present, in order to identify those methods of interventions that have been empirically evaluated in specific types of offender populations, and with what degree of success. In other words, do we have any convincing evidence (i.e., from methodologically sound investigations) that reducing or eliminating substance use in offenders reduces recidivism rates?2 As we will soon discover, this very simple question soon becomes very complex and leads to the following type of further questions. For example, is there any evidence that particular treatment modalities, or combinations of treatments, are differentially effective for offender populations? Do some treatments work better for some “types” of offenders? How do we determine which “types” of offenders to intervene with? Which substances should we concern ourselves? Are some substances more criminogenic than others, or should our goal be to eliminate all substance use? Does compulsory treatment work, or do offenders have to be willing participants in treatment in order for it to be effective? What about treatment goals for offenders? Is abstinence the only reasonable goal, or are moderation and harm reduction goals appropriate targets for some offender population?
In order to provide a context wherein these issues can be addressed, this chapter is organized in four sections. First, we explore the nature and extent of the relationship between criminal behaviour and substance use and abuse. Theoretical models and definitional issues are briefly presented to identify significant etiological factors and to clarify terms. The second section will focus on treatment and major methodological issues in the out-come evaluation of substance abuse treatment programs, and describes and reviews models of treatment and their related modalities of intervention. In the third section, we address the heterogeneity of substance abuse disorders, and introduce the concept of matching offenders to treatment modality to improve treatment outcomes. Finally, the results of the treatment outcome studies of the Offender Substance Abuse Pre-release Program as well as the Choices Program recommendations for future directions in treatment development and research are summarized.
Before we can examine the effects of treatment, it is important to clarify exactly what behaviour(s) we are targeting with our interventions. A variety of terms are often used interchangeably in the literature including, “Substance Abuse”, “Substance Misuse”, “Chemical Dependence”, “Substance Dependence”, and “Addiction” without any clear consensus as to their operationalized meaning. This difficulty in reaching a consensus on definitions no doubt results from the divergent conceptual frameworks that different investigators and clinicians hold.
In the field of alcoholism in the United States, the most widely held model is the medical or disease model (Nirenberg & Maisto, 1990). In this model, alcohol abuse is conceptualized as a disease entity that is progressive and irreversible, (Jellinek, 1960). In more recent years, the model has been expanded to include licit and illicit substances, and some behaviours including gambling and sexuality (Peele, 1984). According to this model, treatment can never cure the alcoholic, or drug addict, but can arrest the progress of the disease if abstinence is strictly adhered to. Twelve-step pro-grams are based on a disease model conceptual framework. However, the international literature has repeatedly confirmed the heterogeneous nature of alcohol and drug abusing populations. Different etiologies and presentations have led to multi-dimensional, bio-psycho-social conceptual models of substance use disorders that recognize the complex interrelationships between psychological, biological, and social variables. These multivariate models suggest that a range of treatment modalities and goal alternatives will be required if the diverse needs of those with substance use disorders are to be met.
One of the most widely used methods to identify (diagnose) substance use disorders is provided in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV-R, 1994), the major classification system for mental disorders. Both the DSM IV-R and the International Classification of Diseases (ICD-9 WHO, 1979) are loosely based on a conceptual framework first developed by Edwards and Gross (1976). In this framework, the central concept, alcohol dependence, is defined as a syndrome with a number of essential elements, such as narrowing of the drinking repertoire; salience of drink-seeking behaviour; increased tolerance; repeated withdrawal; drinking to relieve or to avoid withdrawal symptoms; a compulsion to drink; and reinstatement of the syndrome after abstinence. These elements were considered to exist in a matter of degree, resulting in a syndrome with a range of severity from none to severe. Importantly, Edwards et al. assert that alcohol-related physical, social and psychological disabilities (problems) could be experienced without the individual necessarily suffering from the dependence syndrome. Although in recent years it has been receiving increased criticism, the alcohol dependence syndrome has been identified as having important implications for assessment and the selection of treatment goals (Orford & Kedie, 1986).
Within DSM IV-R, this underlying dimensional conceptualization has been translated into two major diagnostic categories: Substance Use Disorders and Substance-Induced Disorders. Substance Use Disorders subsumes two diagnoses, an Abuse diagnosis and a Dependence diagnosis. Abuse is considered to be a recurrent and maladaptive pattern of use that causes clinically significant impairment in any of social, legal or occupational functioning, or use in situations that are physically hazardous over a twelve-month period. It also includes substance use that continues despite persistent or recurring social problems caused or exacerbated by the effects of the substance. A diagnosis of Substance Dependence requires evidence of three or more symptoms from those noted above. In addition, evidence of physical dependence on the substance as indicated by increased tolerance or withdrawal symptoms after termination of use are additional criteria. Importantly, once an individual qualifies for a diagnosis of Dependence, DSM-IV requires that future episodes of substance related problems receive a diagnosis of Dependence. This suggests that once an individual has developed a physical dependence on a substance there is a significant qualitative change that is permanent.
In DSM-IV-R, this diagnostic model is applied to eleven different categories of psycho-active substances including; alcohol, amphetamine like drugs, cannabis, nicotine, cocaine, hallucinogens, inhalants, opiates, phencyclidine (PCP) and sedative hypnotics or anxiolytics. DSM-IV-R also provides for a polysubstance diagnosis. Thus DSM-IV allows for the systematic diagnosis of a full range of substance use disorders. One of the major deficiencies in the offender substance abuse treatment literature, has been the failure to operationalize the substance related problem under investigation. Substance use patterns of treated populations of offender are often not even described, let alone quantified. Nor is it typical for investigators or clinicians to apply any systematic classification or diagnostic criteria, like DSM-IV-R or other objective substance abuse measures in their selection or description of subjects. The treatment needs of a physically dependent morphine addict may be quite different from those of the property offender who uses marijuana “recreationally” on weekends. A failure to specify the type(s) of substance(s) used, or to describe the pattern of use, seriously limits inferences that can be drawn or generalizations that can be made from many treatment outcome studies. With these caveats in mind, we now examine the kinds of available data that estimate the nature and extent of substance abuse-problems in offenders.
A national survey of incarcerated American offenders (U.S. Bureau of Justice Statistics, 1983) found that one third of all inmates in State prisons drank heavily just prior to committing the offence for which they were convicted. Habitual offenders and persons convicted of assault, burglary and rape were more likely to be very heavy drinkers. With regard to drug use, approximately one third were under the influence of an illegal drug at the time they committed the offence for which they were incarcerated. In this survey, drug use was most frequently associated with a drug-related offence or burglary and least often with violent crimes. However, the U.S. Drug Use Forecasting Program found that 60% of parolees for violent crimes tested positive for a least one drug (Bureau of Justice Statistics, 1990). Violent “predatory offenders” and those who are high-frequency drug users were the most likely to commit many types of crime, including violent crime, at high rates. They are also most likely to use many different kinds of drugs, particularly heroin and/or cocaine, (Chaikin & Chaiken, 1990; Johnson et al. 1985). Gropper (1985) reported that drug-abusing offenders commit a high percentage of the reported violent crimes, and that drug addicts commit more crimes when addicted.
Surveys in Canadian offenders have found that approximately 80% of offenders report substance use on the day of their offence, most frequently a combination of alcohol and drugs, (Lightfoot & Hodgins, 1988). In our survey, we utilized objective measures (e.g., Alcohol Dependence Scale, Drug Abuse Screening Test) to provide quantitative estimates of the severity of alcohol and drug problems. Surprisingly, we found that relatively few offenders' scores indicated alcohol dependence (26%). However, 68% reported moderate to severe drug abuse scores. Using a Computerized Lifestyle Assessment at intake to Canadian federal correctional institutions, Weekes (1993) has assessed the level of severity of alcohol and drug problems in large samples of Canadian offenders and have described similar findings. Approximately 50% of offenders had no evidence of drug-related problems, and 50% reported no alcohol-related problems. Low levels of alcohol problems were more common than drug problems (35% vs. 20%), but larger percentages of offenders reported more severe drug-related problems (i.e., 12% moderate drugs vs. 9% moderate alcohol; 12% substantial drugs vs. 5% substantial alcohol; 4% severe drugs vs. 3% severe alcohol). Approximately 36 % of offenders had moderate to severe substance abuse problems, and were more likely than low severity offenders to have used a substance on the day of the current and previous offences. Assaultive offences were identified more frequently in moderately dependent alcohol users, and higher frequencies of drinking and levels of dependence were associated with incarceration for violent offences.
With regard to women offenders, in our survey of federally incarcerated women (Lightfoot & Lambert, 1991), women were less likely than incarcerated men to report symptoms of alcohol dependence. Approximately 65% of women reported some level of drug related problems, the majority (53%) at moderate to severe levels. Twenty-eight percent reported moderate to severe symptoms of alcohol dependence. Sanchez and Johnson (1987) found that women offenders who are habitual drug users committed lower rates of violent crime but had higher rates of prostitution and shoplifting than male offenders.
These data clearly show that there is a range of treatment severity in offender populations, with approximately 40% using at levels associated with a moderate to severe level of problems. These data also indicate that offenders with more severe sub-stance abuse problems are in general, at higher risk to recidivate violently. These data imply that there is a need for a range of substance abuse interventions, geared to both risk and need characteristics, for offender populations.
The type of prevalence data described above has clearly established the correlation between substance use and crime. Attempts to explain this phenomenon in causal terms, struggle with the eternal “chicken and egg” question. Do substance use and abuse lead to or cause criminal behaviour, or is substance abuse just part of the generally deviant lifestyle characteristic of individuals with the propensity to anti-social behaviour? The answer appears to be that both phenomenons occur. Thus, individuals with Conduct Disorder are predisposed to abuse substances as well as to engage in criminal behaviour. This group might be characterized as “primary criminals”. There is a second group, however, who develop a substance use disorder, and then begin to engage in criminal behaviour to support their addiction. This group we might describe as primary substance abusers, with criminality or adult anti-social behaviour appearing secondarily. Rada (1973) has suggested this kind of distinction in his study of rapists. It is also significant in this regard, that a second “type” of Antisocial Personality Disorder (ASPD) has been identified in samples of substance abusers. Brooner and colleagues (1992), in a study of opiate injectors, found that 44% met the full criteria for DSM-III-R ASPD, and an additional 24% had the adult criteria but lacked the childhood conduct disorder criteria. Thus 68% would have been diagnosed ASPD if the childhood trajectory had been ignored. In a study of adult opiate injectors, 44% of men were classified as ASPD, and an additional 33% were classified as adult anti-social behaviour (AABO) only (i.e., did not meet child-hood criteria). The rates for women were 27% ASPD, and 42% AABO (Cottler, Price, Compton, & Mager, 1995). Although the fully diagnosable group were more irritable and aggressive, and reported more adult criteria, drank more and were more likely to have been involved in treatment, they were indistinguishable in terms of the rates of substance abuse related problems, co-morbid psychiatric disorders, and type of adult anti-social behaviour demonstrated. Cottler et al. suggest that AABO may be the late-onset subtype of anti-social personality similar to the Type I or Type II alcohol disorder (Cloninger, 1987). It is important to state at this point that it is of more than an academic interest to determine what came first, criminality or addiction. The diagnosis of ASPD has been associated with particularly poor outcomes in substance abuse treatment (Rounsaville, Dolinsky, Babor, & Meyer, 1987). As will be argued later, treatment for substance abusers with anti-social personality may require additional, or different, specialized interventions, in order to be effective.
Many therapeutic modalities have been employed in the treatment of substance abuse and dependence (Miller & Hester, 1986; Institute of Medicine, 1990). Table 14.1 provides a summary of the primary substance abuse interventions which have been described in the literature It should be noted at the outset that the development of most treatment interventions has been directly or indirectly related to an underlying etiological model. For example, proponents of biological models that emphasize the role of genetic and bio-physiological factors, search for and employ drug treatments and typically stress abstinence goals. In contrast, those who adopt a social learning (SL) framework emphasize the relationship between the individual and the environment. These treatments intervene by modifying the individuals behavioural coping skills and cognitive processes in order to improve the individuals ability to function in the environment. SL treatments tend to address deficits that are thought to be functionally related to the substance use disorder. Typically the goals of treatment in SL based treatments are multivariate, and reduction or elimination of substance abuse is only one of the desired outcomes. Sociocultural models acknowledge the impact of social and cultural influences on individual substance use behaviour, and have led to the development of interventions at the social policy level. These types of interventions include reducing the availability of substances through restricted access, interdiction and government taxation levies. Broad spectrum treatments often include a variety of treatment components reflecting several conceptual models. In the Community Reinforcement program, for example, drug treatments (Antabuse) is combined with contingency management and skill training (Azrin, Sisson, Meyer, & Godley, 1982).
Although we usually refer to treatment as a unitary entity, Ross and Lightfoot (1985) suggest that it can be usefully conceptualized as a complex process composed of a number of stages including:
Most treatment outcome studies have tended to focus on the Active Treatment phase. Few have examined the other phases of treatment, or the interaction between interventions at different phases, despite the fact that increasingly, aftercare is being identified as at least a significant component of treatment as active treatment (Ito & Donovan, 1986). For some types of sub-stance abusers, assessment alone can be an effective intervention (Edwards et al. 1976).
A few studies have empirically examined detoxification as a stand-alone intervention. They have not found detoxification alone to be related to long term behaviour change (Simpson & Savage, 1982). Detoxification is, therefore, usually considered only the first phase of a comprehensive treatment program, rather than a stand-alone intervention.
Despite the wide range of treatment interventions, the offender substance abuse treatment outcome literature deals primarily with three forms of treatment: Methadone Maintenance (MM), Therapeutic Communities (TC), and Outpatient Drug Free Treatment Programs (OP). Before reviewing studies related to these modalities, it is important to address the methodological issues confronted when conducting outcome studies.
TABLE 14.1 Types of offender alcohol and drug treatment
|Antidipsotropic Drugs:||NE alone|
|Serotonin Reuptake Inhibitors:||Preliminary|
|Zimelidine, Citropram, Fluoxetine, Desipramine|
|Opiate Agonists:||P, reducing but not eliminating crime|
|Social learning based treatments|
|Contingency management/Contingency contracting||E|
|Broad spectrum therapies||E|
|Individualized behaviour therapy|
|Behaviour self-control thinking||E|
|Monitoring & Surveillance||E|
|Adult Children of Alcoholics|
|E||- Effective in Quasi Experimental and/or Controlled Studies|
|NE||- No clear evidence of effectiveness from controlled studies|
|Preliminary||- Small Samples, uncontrolled designing|
Reviews since the 1960s (e.g., Hill & Blane 1967) have demonstrated that outcome evaluation studies of alcohol and drug abuse have suffered from design problems, such as lack of standardized and operationally defined subject populations, lack of appropriate comparison or control groups, retrospective rather than prospective evaluation designs, inadequate pre-treatment baseline data, inadequate outcome measures, and insufficient follow-up periods (Acierno, Donohue, & Kogan, 1994; Breslin, Sobell, Sobell, & Sobell, 1997; Longabaugh, 1989; Goldstein, Surber, & Wilner, 1984). Methodology reviews indicate that drug abuse treatment outcome studies are weaker than alcohol treatment or mental health treatment outcome studies (Martin & Wilkinson, 1989).
Although the experimental design with random assignment to experimental and control groups has long been considered the “gold standard” in research, increasingly its limitations when applied to the field have been noted. Dennis (1990) identified six potential methodological problems when using randomized experiments to evaluate intervention programs under field (real world) conditions. These include: treatment dilution, treatment contamination, inaccurate caseflow and power estimates, violations of the random assignment process, changes in the environmental context, and changes in the treatment regimes. Dennis describes a number of methods to improve the quality of random field experiments, but he also suggests that we should acknowledge that field research is unlikely to ever be ideally implemented. Instead, he recommends methods for addressing these problems in order to improve estimates of treatment effects.
Expert reviews of the efficacy of substance abuse treatment (Institute of Medicine, 1990; Miller & Hester 1986) have consistently concluded that there is no “magic bullet” (i.e., single treatment), which is effective for al persons with a substance use disorder. In general, treatment has been found to be superior to no treatment with approximately two-thirds of treated clients demonstrating improvement in life functioning (Addiction Research Foundation, 1984; Institute of Medicine, 1990). Half of the improved clients are likely to abstinent or using at modest levels at follow-up. Controlled studies, with unselected treatment populations, have compared outpatient counselling to residential treatment and have found no significant overall differences in effectiveness (Annis, 1984; Institute of Medicine 1990). There is also some data indicating that providing more treatment than needed may reduce treatment effectiveness (Annis & Chan, 1983; Institute of Medicine 1990). This type of data has led managed care providers to seriously question the cost-effectiveness of the inpatient residential treatment program, when short-term outpatient treatment may be as effective. However, it is very important for our purposes to note that these data have been collected on mixed samples of substance abusers. There is some data that indicates that clients with more severe problems do better in residential treatment (Institute of Medicine, 1990). Although substantial percentages of clients in community substance abuse treatment programs have had some criminal involvement, they represent a different population than that typically seen in correctional settings.
One of the largest evaluations of treatment outcome, to care-fully examine the role of criminal history variables, was the Drug Abuse Reporting Program (DARP) (Simpson & Sells, 1982). This program of research involved over 4,000 subjects participating in five different types of treatment including; methadone maintenance (MM), therapeutic community (TC), Outpatient Treatment, Outpatient Detoxification (OD) and Intake Only (no treatment). Clients with the greatest criminal involvement had the poorest outcome. MM, TC, and TF treatments did not differ significantly from each other, but were more favourable than those completing outpatient detoxification and intake only. Simpson et al. were unable to find an optimal match between post-hoc empirically derived client types and treatment types. However, the power of the statistical tests used was low and these results cannot be considered conclusive. McLellan and associates (1980) have found that pre-treatment level of legal problems (in addition to psychiatric status and employment) to be powerful predictors of negative treatment outcome.
These data suggest that criminality is a significant factor which independently affects treatment outcome. Specialized programs that are specifically designed for offender populations (where the levels of criminality will be significantly higher than in community programs) may have better outcomes than non-specialized or generic substance abuse programs.
Indeed, research is accumulating which indicates that treatment efficacy may be enhanced by matching individuals to treatment on the basis of social, demographic, personality or cognitive variables. For example, there is some evidence that intensive treatment is more effective for individuals with more severe substance abuse problems (i.e., higher levels of dependence) (McLellan, Luborsky, Woody, O'Brien, & Druley, 1983). What do we know about substance abuse treatment and improvements in efficacy related to matching in offender populations? There are methodological and ethical problems that make matching and random assignment to treatment, problematic. This may in part account for the fact that most outcome studies with offenders have concerned themselves with evaluating a particular modality rather than exploring the interaction between offender and treatment types. As noted earlier, the modalities that have received the greatest amount of attention are therapeutic community treatments, and methadone outpatient (drug-free) treatment. Despite their proven effectiveness in controlled outcome studies (Miller & Hester, 1986) very few behavioural treatments have been applied to or evaluated in correctional populations, although some treatments may include behavioural components.
Therapeutic communities typically involve a highly structured, long term (8 to 12 months), residential program which includes a highly confrontational form of group therapy, resocialization, progressive responsibility and gradual re-entry into the community. The use of recovering addict counsellors is considered an essential component of treatment. In their review of these programs, Gerstein and Harwood (1990) concluded that the Stay'n Out Program (New York), Cornerstone (Oregon State Hospital) and the California Addict Program, have demonstrated significantly reduced re-arrest rates for offenders who completed these pro-grams. To date however, there has been no controlled evaluation of therapeutic community programs. Wexler, Falkin, and Lipton (1990) conducted a quasi-experimental evaluation of the Stay'n Out Program, a prison based therapeutic community program, and compared it to milieu therapy, counselling, and a no-treatment control group. The TC group had the lowest percent of re-arrested clients (17.8%), and the highest percent positively discharged from treatment as compared to controls. However, no statistical correction was made for the fact that the milieu therapy group had significantly higher pre-treatment levels of criminality than the TC group. Group differences' were not significant for the mean time until arrest, or for positive parole discharge. This study also included three women groups, including a TC group, a Counselling Group and a No treatment group. There were no significant differences in outcomes among the those three groups, however sample sizes were small and power was therefore limited.
One of the major issues addressed in the outcome of TC has been the relationship of time in treatment to outcome. Wexler et al. found that TC's effectiveness in reducing recidivism increased as time in program increased but tapered off after 12 months. No information was provided about changes in substance abuse, so it is very unclear whether the reductions in recidivism observed were related to changes in patterns of substance use.
Field (1985) evaluated the Cornerstone Program, a 10-12 month intensive residential program with a 6-month aftercare program. In addition to the usual elements of confrontation and peer counsellor involvement, skill training in the areas of basic education and life skills was included. There was no control group but graduates were compared to three comparison groups; program dropouts, Oregon parolees and Michigan parolees with some history of alcohol and drug use. A variety of outcomes were measured including changes in self-esteem, staff rated changes in psychiatric symptomatology, and increases in knowledge on a 78-item pre-post treatment instrument. Recidivism was measured retrospectively and addressed two variables : the number of offender not returned to prison during the 3 years after their parole (including revocations and new convictions), and the number not convicted of any crime in this time period. There was statistically significant differences between program graduates and Comparison Group II on both outcome variables with 54.2 % of graduates not convicted of any crime during follow-up and 70.8% not returned to prison vs. 36.3 and 62.9% in the comparison group. Changes in alcohol and drug use were not reported, nor were the demographic characteristics of comparison group subjects compared statistically to those of program graduates. Although it was asserted that the comparison group did not have the same degree of chronic substance abuse nor chronic criminality of the treated group, this was not demonstrated. In addition, the number of program dropouts (greater then 30 days) was not reported, and it is therefore not possible to determine if the outcomes were positively biased as a result.
A Multistage Therapeutic Community in Delaware was evaluated, which provided a “transitional” TC in the community for parolees. Six-month outcomes were analyzed in a sample of 457. Groups receiving transitional TC, and TC in prison and the community, had significantly lower rates of drug relapse and criminal recidivism (Martin, Clifford, & Inciardi, 1995). The authors suggest that these data support the value of a continuum of treatment in the treatment of heroin dependent offenders.
A major problem with TC's has been that program completion rates are low with only about 15-25% of admissions completing the full program, (Institute of Medicine, 1990). Those who remain in treatment show significant improvement at follow-up with rates approximating the average rates described above. The relatively higher costs combined with lower retention rates suggests that this treatment be reserved from those who with severe problems who have failed to benefit from less intensive interventions.
Methadone represents only one, of a range of pharmacotherapies that have been used in the treatment of substance abuse disorders. It has been one of the most frequently researched treatment modalities with offenders. Methadone is a synthetic opiate agonist that occupies opiate receptors in the brain. It does not produce the same degree of euphoria as heroin, but because it is medically prescribed, it does provide the severely dependent heroin addict with a legal alternative to drug use. Methadone treatment programs have consistently been found to reduce the rates' of drug use in heroin-addicted offenders (Ball, Shaeffer, & Nurco, 1983; Gerstein & Harwood, 1990). Simpson and Savage (1982) identified two subtypes of methadone treatment; Adaptive and Change-Oriented. In Adaptive programs, drug abstinence is considered to be a long-term and often unrealistic goal. Individualizing and adapting treatment to the individual needs of the client is paramount. Change-oriented Methadone Maintenance program emphasized abstinence as a goal and the need to resocialize the client through rigid structure and a high level of intervention. Despite these differences in program emphasis, no differences in outcomes between these two forms of methadone treatment were found. In addition to the lower costs, higher retention rates, and greater appeal associated with methadone treatment, there is also evidence that injection drug use and risk of HIV infection is decreased by methadone treatment (Ball et al. 1988; Hubbard et al. 1988).
The Drug Free Outpatient Treatment is the third type of treatment that has received a great deal of attention in the offender substance abuse literature. These programs are very diverse, ranging from highly structured individual or group therapy to very unstructured self-help programs and with rare exception, they have not been subjected to careful outcome analysis. Outpatient drug clients, in fact, may have different characteristics than those referred for methadone maintenance or TC treatment. An example of a Drug Free Outpatient Treatment program is the Kentucky Substance Abuse Program (KSAP) (Vito, 1989). KSAP provided “self-help” counselling sessions and referral to appropriate community agencies, to probation and parole clients on a service con-tract with a private provider. The nature and “dose” of treatment wasn't described. One-year outcomes were evaluated in a mini-mum 6-month follow-up by comparing graduates to a matched comparison group and to program dropouts. Clients were described as representing a “high risk” group based on risk scores and histories of severe alcohol abuse. Despite their poorer prognosis, KSAP graduates had significantly lower arrest, conviction and incarceration rates for new felonies than the comparison group. They also had a higher rate of arrest and conviction but not incarceration. Latessa (1988) found similar findings in a study of alcoholic probationers (Ohio-STOP program).
Moon and Latessa (1994) evaluated an outpatient drug treatment program, the Chemical Offender Program (COP) for felony offenders. This three-phase program was educational in nature but also had a 12-step component, and a drug-testing component. Acupuncture was also evaluated in one of the treatment conditions. Results indicated no differences in rates of arrest and conviction for misdemeanour and felony offences, but experimental subjects had fewer felony arrests and convictions. Acupuncture was not found to be effective. As the authors acknowledge, small samples, and short follow-up period limited this preliminary study.
Comprehensive evaluations of outpatient treatments in the DARP (Simpson & Sells, 1982), have found outpatient treatment to be equally effective to methadone maintenance, and therapeutic community programs.
Our review of the substance abuse treatment outcome literature in offenders reveals some consistencies but also some differences from the results of reviews in unselected non-offender populations. Anti-social personality and criminality have consistently been related to poorer outcomes in all types of treatment. In general, while non-offenders do not have better outcomes in longer term or more intensive programs, offenders have been reported by some investigators to have better outcomes the longer they remain in treatment. Well designed studies with sophisticated statistical analyses indicate that offenders appear to benefit equally from therapeutic community, milieu therapy and drug free outpatient treatment programs. While cognitive-behavioural treatments have been found effective in controlled outcome evaluation in non-offenders, these interventions are seldom used or evaluated in offenders. Methadone appears to be an effective treatment for opiate addicts in both offender and non-offender populations. Miller and Hester (1986) have argued that there is no controlled empirical evidence that confrontation in therapy is an effective strategy to produce behaviour change, while advocates of the TC assert that it is an essential component of effective therapy. TC's advocate the use of peer counsellors (ex-offender/addicts). Empirical studies in the general psychotherapy literature and the substance abuse literature suggest that therapists who are judged more skilled and competent by peers and who have the ability to form a therapeutic alliance (Luborsky et al. 1985; Miller & Sovereign, 1989), tend to foster better client outcome.
We have developed a hybrid model that incorporates findings from the criminological and substance abuse literature in order to develop a fresh and innovative approach to the treatment of substance abusing offenders. Expert panels in various jurisdictions (e.g., National Institute of Medicine, 1990; Ontario Ministry of Health, 1988) have sought to broaden the conceptualization of substance abuse problems to ensure a comprehensive and coordinated approach to substance abuse prevention, early identification, treatment and rehabilitation. As can be seen in Figure 14.1, the essential conceptual element of this model is that of the “Risk Continuum,” which posits that as consumption of a psycho-active substance increases so does the probability of experiencing a health, social, or psychological problem. This model also acknowledges the emergence of problems related to acute incidents of substance use, and not just to chronic high dose patterns of intake. The Risk Continuum model encourages the development of a range of interventions, to address the widely varying risk levels that individuals experience. Under this model, primary prevention activities are aimed at those individuals who are not consuming the substance or who are consuming at very low risk levels. Early intervention (secondary prevention) programs targets individuals who are just beginning to experience problems related to their substance use, while treatment and rehabilitation programs are directed only toward those who were experiencing serious health, psychological or social problems. The concept of matching individuals to level and type of treatment is fundamental to the development of a comprehensive cost-effective response to substance abuse problems.
Figure 14.1 Program and service strategies in relation to the risk continuum
Hodgins and Lightfoot (1988), Lightfoot and Hodgins, (1993) have empirically developed a typology of substance abusing offenders. The purpose of trying to identify offender types is to allow for the development of treatment programs “tailor-made” to address the specific needs of these offenders. Hodgins and Lightfoot surveyed the literature to identify all potentially significant matching variables, and using cluster analysis were able to identity four “types” of offenders. One of the primary underlying dimensions of the typology was that of substance problem severity, the other was problem substance type. Thus some offenders reported problems primarily with alcohol, while others reported primarily illicit drug problems. Two other variables significantly differentiated groups; psychopathology and organic impairment.
Table 14.2 provides a brief overview of each of the offender types and the type of treatment that is suggested based on the characteristics of the type. The four types included a Drug Abuser (DA) Group, an Alcohol Abuser (AA) Group, an Emotionally Distressed Poly Drug Abuser (EDPD) Group, and an Organically Impaired Alcohol & Drug Dependent (OI) Group. This latter group was the most impaired with serious levels of alcohol and drug abuse combined with marital, family and leisure problems. In addition, this group had a lower mean IQ, and showed evidence of organic damage on neuropsycholgoical screening tests. A fifth group was identified that were basically free of alcohol and drug problems and who therefore did not require treatment. It is important to note that two variables, psychopathology, and cognitive impairment, which have been consistently identified as important predictors and matching variables from the outcome literature, were also identified with our offender sample as also highly important potential matching variables. Lightfoot and Hodgins have described how treatment for these four types could be matched to offender needs through the development and integration of treatment elements which address the special needs and skill deficits which each of the offender types presents.
TABLE 14.2 Typology of substance abusing offenders (Lightfoot & Hodgins, 1993)
|Group 1: Non-Abusers||20.9%|
|More socially stable|
|High employment stability|
|Low role alcohol and drugs in crime|
|2.2 standard drinks/day|
|1.2 drug classes|
|Group 2: Drug Abusers||25.2%|
|High need for assistance with drug problems, marital, family, and employment|
|Use of 4.5 drug classes|
|50.8% wish to quit alcohol and drug use|
|Low employment stability|
|Group 3: Alcohol Abusers||23.0%|
|Average ADS in moderate range|
|Consume 14 drinks/day|
|54% wish to quit|
|High need for assistance with alcohol problems|
|View alcohol and drugs as playing significant role in crime|
|Group 4: Emotionally Distressed Polysubstance Abusers (Dual Diagnosis)||13.0%|
|Low social stability|
|Low employment stability|
|45% wish to quit|
|High need for assistance with alcohol, employment, and emotional|
|2.3 drug classes in month before charge|
|Highest GHQ* (emotional distress)|
|Group 5: Organically Impaired Alcohol and Drug Abusers||17.6%|
|Impaired intellectual function|
|Substantial ADS and DAST Scores|
|4.1 drug classes|
|Alcohol and drugs played major role in crime|
|Lower WAIS and impaired TRIALS B|
|High need for assistance in all areas|
|93% indicate desire to quit alcohol/drug use|
|* GHQ = General health questionnaire|
Development of this typology has led to the development of three core programs to address the needs of offenders: the Offender Substance Abuse Pre-release Program (OSAPP) (Lightfoot, 1993a; 1993b; Lightfoot & Baker, 1989), the Choices Program (Lightfoot & Boland, 1993), and the Alcohol, Drugs, and Personal Choice Program (Lightfoot, 1995).
In 1992, the Correctional Service of Canada (CSC) introduced a framework for the identification and treatment of sub-stance abuse which is consistent with the Risk-Continuum approach described above. The CSC model, depicted in Figure 14.2, consists of five components that are designed to address the offenders needs from entry into the system until warrant expiry. Initial screening to identify substance abuse problems is made with the Computerized Lifestyle Assessment Instrument (Weekes et al. 1993) as part of a comprehensive front-end assessment. An alcohol and drug education induction module is provided to all new offenders, following which they are expected to participate collaboratively with their case manager in the identification of the most appropriate treatment based on their risks and needs. Offenders with “none to low” levels of substance abuse problems or who were involved in the sale and distribution of drugs are referred to Alcohol, Drugs and Personal Choice program (10 3-hour sessions) (Lightfoot, 1995). The objectives of this program are to modify attitudes to drug and alcohol use. Clients with “low to moderate” problems are referred to Choices, a brief treatment program with 3-month follow-up. Those with moderate or higher levels of problems are referred to the more intensive Offender Substance Abuse Pre-release Program (OSAPP). Follow-up and support are then provided after the completion of treatment through participation in maintenance groups that are available in both the institution and the community.3
|Developing a Model for the Provision of Substance Abuse Treatment. (1993) Ottawa: Correctional Service of Canada|
The Offender Substance Abuse Pre-release Program is an institutionally based, intensive treatment program designed to address offenders with intermediate to severe alcohol and drug problems. Offenders who participate in the program are usually within a year of release to the community. The program consists of 26 three-hour group sessions, and three individual counselling sessions. The major units are: alcohol and drug education, self-management training, social skills training, substance use and work, leisure and lifestyle, and pre-release planning.
It is well accepted in the addiction field that substance abusers “deny” that their substance use is a problem. Programs have typically attempted to break down denial by challenging and con-fronting the client. Miller et al. (1988) have suggested that motivation is a dynamic rather than a static characteristic of individuals. A primary premise of the OSAPP and Choices programs is, therefore, that motivation for change is an important initial target in treatment. In other words, it is the responsibility of the program to develop motivation in unmotivated clients, rather than a criterion for rejection from treatment involvement. This is obviously an very important issue in treating offenders, the majority of whom will be mandated to treatment rather than being voluntary participants. In these circumstances, the initial attitudes of participants range from indifferent to hostile.
Prochaska and DiClemente (1986) have proposed a trans-theoretical model of the change process that incorporates a dynamic view of motivation and behaviour change.4 They note that different “processes” of change are involved at each stage and therefore require different interventions. The OSAPP and Choices programs thus employ sequential interventions designed to address each of the stages of change. Table 14.3 describes the goals of treatment and related program strategies, and an overview of the nine OSAPP program units is provided in Table 14.4. Both the substance abuse treatment literature (Miller & Hester, 1986), and the criminological literature (Gendreau & Ross, 1982; Andrews et al. 1990) have highlighted the superior efficacy of cognitive behavioural treatments with offenders.
TABLE 14.3 Components of the offender substance abuse pre-release program and stage of change
|Stage of change||Goal of intervention||Program strategy|
|Contemplation||Increase Awareness||Alcohol and Drug Education|
|Action||Learning Skills to Assist in Behaviour Change Process||Behavioural Self-Control Training|
|Maintenance||Apply skills||Social Skill Training|
|Employment Skills Refresher|
|Relapse||Learn Skills and Attitudes to Prevent or Reduce Severity and Frequency of Relapse||Relapse Prevention|
OSAPP interventions are therefore cognitive and behavioural, and include role-playing and rehearsal to facilitate skill acquisition. Both programs are delivered primarily in group format using the principles of “inductive” adult learning, rather than a didactic lecture format. Individual counselling sessions are also incorporated at strategic points in the treatment process. A detailed program curriculum manual provides specific protocols for each session. Group Facilitators must complete a comprehensive training program followed by clinical supervision until they reach the required level of competency. At this point, they are certified as facilitators but they continue to participate in a program of ongoing professional development to maintain their certification. These measures are intended to ensure the integrity of the treatment and to prevent program drift over time.
TABLE 14.4 Offender substance abuse pre-release program overview
|Individual Assessment Interviews|
|Unit I: Introduction -- 2 Sessions|
|Individual Counselling Session I|
Unit II: Alcohol & Drug Education -- 5 Sessions
|Unit III: Self Management Training -- 7 Sessions|
|Self-Control Training, Problem Solving, Assertion Training|
|Individual Counselling Session II|
Unit IV: Social Skills Training -- 3 Sessions
Unit V: Job Skills Refresher -- 2 Sessions
Unit VI: Leisure and Life Style -- 1 Session
Unit VII: Pre-release Planning -- 2 Sessions
Unit VIII: Relapse Prevention and Management -- 2 Sessions
Unit IX: Post-Testing and Graduation -- 2 Sessions
|Individual Counselling Session III|
Evaluation has been built into the program from the outset. A comprehensive initial structured assessment, provides essential pre-treatment data. Pretesting is followed by post-testing at the end of intensive treatment and again at the end of maintenance. A battery of measures targeting the knowledge, attitudes, and skill targets has been developed and refined during the preliminary stages of evaluation. Because of its developmental nature, our pro-gram evaluations to date have focused primarily on the extent to which these secondary treatment targets have been achieved.
Each offender presents with a unique pattern of strengths and deficits. Therefore, rather than simply looking at group change scores, we (Lightfoot & Barker, 1989; Lightfoot, 1993b) developed a methodology for examining the pattern of significant pre-post changes in individual participants, before aggregating and analyzing the change score data. Results of the preliminary evaluations demonstrated that most program participants improved significantly on two or more of the post-test measures. Efforts are ongoing to assess long term outcomes as well as the relationship of changes on secondary treatment targets to the ultimate treatment targets of substance use and recidivism. A 15-month follow-up study of 324 OSAPP treated offenders (Weekes, Millson, Porporino, & Robinson, 1994) found that most demonstrated significant improvements on the pre-post test measures. Over 90% of offenders who completed the program were released, and 30.2% of them were readmitted into custody within the 15-month follow-up period. Rates of readmission varied directly as a function of substance abuse severity level, with offenders demonstrating moderate to substantial substance abuse problems much more likely to be readmitted than those with low problem severity. In addition, readmission rates were also directly related to the number of pre-post measures on which offenders demonstrated improvement. Only 19% of offenders who improved on pre-post test measures reoffended, while 36% of those who showed no improvement were readmitted. These findings were also confirmed in a survival analysis. A large scale evaluation of OSAPP (September, 1999) included a sample of 2,731 offenders from 29 federal facilities between 1992 and 1997. A sample of 786 OSAPP participants were matched with offenders to form the pool of potential comparison cases. Twelve-month post release outcomes were examined and demonstrated statistically significant differences for overall readmissions and, reconvictions for violent offences, that 42% of OSAPP participants were readmitted compared to 49% of matched cases, a 14% reduction in recidivism (readmission). There was a 30.6% reduction in new convictions in OSAPP participants, and a 53% reduction in new convictions for violent offences.
Following the development of the OSAPP program, Lightfoot and Boland (1993) subsequently developed a brief treatment and relapse prevention program Choices for federal parolees. Choices is a brief intervention with a heavy emphasis on relapse prevention skills. This program was originally designed to be delivered to offenders released to the community on parole. More recently, it has been introduced into minimum security institutions and is also delivered to low to moderate severity offenders just prior to release from federal institutions. Parole officers refer potential participants for a structured interview and testing to assess suitability for the program. The initial assessment interview also provides an opportunity for the development of a therapeutic relationship with the Group Facilitator. A particularly novel aspect of the Choices program was that parole officers were given training in program delivery and they functioned as co-facilitators for the treatment and maintenance groups. To ensure consistency in our message and our approach, the Choices program was also developed around Miller's dynamic concept of motivation. Table 14.5 provides an overview of the Choices program. Session 1 has as its primary objective the development or enhancement of the participants' motivation to change their pattern of alcohol and drug use, through the discussion of the costs and benefits of drug and alcohol use. Participants complete a cost/benefit analysis (decisional matrix) of their personal substance use and this is intended to influence their goals and to increase their interest in treatment. As is the case with the OSAPP program, evaluation is built into the program and participants complete a battery of pre-tests designed to assess their current level of alcohol and drug related attitudes, knowledge and skills. Session 2 introduces the ABC learning model of addiction, and participants identify their triggers (A's) and payoffs for substance use (C's). In session 3, Problem Solving skills are introduced, followed by behavioural and cognitive coping skill training and practice. Sessions 4 and 5 address the process of relapse. Participants develop a specific relapse prevention and relapse management plans for dealing with their high risk situations. Post testing is also completed in Session 5 as well as individual interviews. In the second phase of the program, participants are required to attend weekly maintenance sessions for a minimum of three months. It is well known that the period of time immediately following release is highly stressful and relapse to substance abuse is frequently observed, often followed by suspension or revocation of parole. It has also been well documented that the three-month interval following the completion of substance abuse treatment is the period of greatest risk of relapse (Marlatt & Gordon, 1985). Participants are therefore required to attend a minimum of 12 weekly maintenance sessions in order to consolidate and build on gains achieved in the intensive treatment phase.
Preliminary evaluation results with a sample of 95 federal parolees indicated that 80% had low-moderate levels of alcohol dependence while 61% had moderate to severe levels of drug related problems. Cocaine was the most frequently identified problem drug, followed by alcohol (28%) and heroin (11.6%). A secondary substance of abuse was identified by 38% of participants; alcohol and THC (12%) were the most frequently identified. The majority of participants identified abstinence as their goal for their primary substance of abuse, while the most frequently (26.3%) identified goal for secondary substances was moderation.
An evaluation of the Choices Program (CSC, 1999) indicated that Choices participants made positive gains on all of the six measures in the pre-post-test battery. Twelve-month conditional release outcomes for a sample of 436 Choices participants were compared to a matched group of offenders. Offenders who only completed the intensive phase of treatment had outcomes that were comparable to the matched comparison group. However, those offenders who also completed the 12-week maintenance phase of treatment had a reduction in the readmission rate of 29% compared to matched controls. There was a statistically significant 56% reduction in re-convictions for maintenance phase completers. Of particular interest was the finding that participation in both OSAPP and Choices had lower readmission rates when compared to those completing only one of the core programs. Continuing the two programs also resulted in significantly lower reconviction rate. These findings tend to attest to the efficiency of providing continuity of care, from the institutional to the community setting. The results to date are encouraging and suggest that a comprehensive program of assessment and treatment can be effectively implemented and co-ordinated throughout the period of incarceration and community supervision.
TABLE 14.5 Choices program overview
|Individual Assessment Interview|
|PHASE II -- BRIEF TREATMENT|
|Session 1:||Alcohol & Drug Knowledge: Developing Motivation for Change Pre-testing|
|Session 2:||Understanding and Managing Your Behaviour|
|Session 3:||Problem Solving|
|Session 4:||Relapse Prevention: Understanding and Preventing Slips|
|Session 5:||Understanding and Managing Slips Post Testing|
|PHASE III -- MAINTENANCE AND GRADUATION|
|Weekly Relapse Prevention Maintenance Sessions Graduation|
Treatment goal selection is one of the most controversial areas in the substance abuse field (Miller, 1986; Peele, 1984, 1987; Wallace 1987a & b), particularly in the treatment of alcohol abuse/dependence (Sanchez-Craig & Lei, 1987). However, a similar controversy is evident in the treatment of other drug dependence disorders (Martin & Wilkinson, 1989). It is particularly important in the treatment of substance abusing offenders (Ross & Lightfoot, 1985). The controversy appears to emanate largely from the strong opposition by traditional (i.e., disease model) program proponents to the research which has indicated that controlled drinking (CD), or moderation is a feasible goal for some substance abusers.
Traditionalists hold that substance abuse disorders are progressive diseases, and that effective treatment requires a commitment to lifelong complete abstinence (Stockwell, 1986). Research, on the other hand, demonstrates that particularly for young single males, moderation goals are more likely to be complied with, and therefore more successful than are abstinence goals (Sanchez-Craig et al., 1984; Sanchez-Craig & Lei, 1987). Controlled drinking is usually defined as including some limit on the amount and frequency of consumption, and drinking which does not result in signs of physical dependence or social, legal, or health problems (Heather & Tebbut, 1989). In a review of the literature, Rosenberg (1993) concludes that controlled drinking outcomes are as frequent as abstinence outcomes in many populations. Sanchez-Craig and Wilkinson (1993) have reviewed the contra-indications to moderate drinking goals and these include: health status, legal status, and personal preferences and beliefs. Others have suggested that degree of dependence is also an important consideration (Miller & Hester, 1986; Rosenberg, 1993), while post-treatment characteristics have recently been identified as important in predicting CD outcomes. This approach has been expanded to the drug use, and harm reduction goals for drug abusers are increasingly being acknowledged as more realistic and achievable for some chronic drug abusers than abstinence.
Within the correctional field this presents a dilemma to therapists who are concerned that they not be seen to condone illegal behaviour (i.e., drug use). In both the OSAPP and Choices program this issue is dealt with head on. We know that a significant proportion of offenders, when asked, identify moderation goals for their secondary substance of abuse, and some in fact identify moderation for their primary substance abuse problem. To deal with this, clients are required to state their substance use goals and they must then carefully consider the consequences (costs/ benefits) associated with their Choice. Using this strategy we have noted that substantial numbers of participants modify their goal choice after treatment, towards an abstinence goal.
Deficits in neuropsychological functioning impairment are common sequelae of substance abuse (Miller & Saucedo, 1985; Parsons, Butters, & Nathan, 1987; Wilkinson & Carlen, 1981). Although severe organic deficits such as Wernicke-Korsakoff Syndrome, are relatively rare in the alcohol abusing population, less severe cognitive impairment can be found in up to 75% of an alcohol abusing population, and 67% of polysubstance abusers. These deficits include visio-spatial, visio-motor, learning, memory and abstract reasoning. Vocabulary and verbal skills are the least affected, thus cognitive impairment is often not easily suspected from conversation or clinical interviews. However, cognitive impairment may result in behaviour that is easily mistaken for other psychological problems such as personality disorder or denial. Therefore, comprehensive assessment and treatment planning for substance abusers, requires an assessment of cognitive function. Unfortunately, neuropsychological functioning is rarely addressed in substance abuse treatment, either with offender or non-offender populations. Treatment for this special needs population are only now being developed (Gordon, Kennedy, & McPeake, 1988). In our research (Lightfoot & Hodgins, 1988), this group of offenders was the most severely dependent and had the greatest range of treatment needs. The development and evaluation of treatment programs specifically designed to address the needs of substance abusing offenders with neurocognitive impairment is a pressing area for future research, and program development.
Offenders who meet the criteria for the diagnosis of Anti-social Personality present a major challenge in substance abuse treatment. These individuals have the poorest outcomes and usually include the most severe cases of substance dependence, and criminal histories. Treatments for these individuals must specifically address anti-social cognitions and attitudes if they are to be effective. It may be that this is the group that requires the high level of treatment intensity provided in TC treatments.
Dual Diagnosis offenders have a second major mental disorder (in addition to their substance use disorder) and represent another special need group identified in our research. This group is specifically addressed in another chapter of this publication and will therefore not be dealt with in any depth here. However, it is clear that unless concomitant psychopathology is addressed, treatment outcomes in dual diagnosis offenders will remain poor.
Substance abuse problems are prevalent in offenders, but offenders vary in regard to the severity of abuse dependence and related problems. The substances most frequently targeted in treatment are heroin and alcohol, although the high rates of cocaine and THC use, and poly drug use of offenders have been well documented. Conducting outcome research in corrections is an enterprise frought with methodological and ethical difficulties. Although methodological problems limit the validity of many studies, our review of the literature indicates that substance abuse treatment does reduce recidivism rates in offenders. Thus far there is no evidence to indicate that any one treatment modality is differentially effective with offenders. The three most frequently evaluated types of treatment, Methadone Maintenance, Therapeutic Communities, and Drug Free Outpatient Treatment, appear to have roughly equivalent outcomes. A range of cognitive behavioural interventions has proven effective in non-offenders, but has rarely been evaluated in offender groups. The development of typology of substance abusing offenders and the subsequent development and evaluation of the OSAPP and Choices programs suggests that cognitive behavioural interventions may be especially effective in addressing the needs of low to substantial severity offenders. Severely dependent, anti-social and cognitively impaired offenders await the development of effective treatments matched to their needs. Criminality and psychopathology significantly and negatively affect treatment outcomes. Improvements in treatment efficacy will require the careful matching of offender types to treatments.
4 For more details on this model, see also Chapter 8 of this Compendium.
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