Integrating substance abuse treatment and criminal justice supervision

Proponents of a pure public safety perspective on the drug problem hold that drug-involved offenders require consistent and intensive supervision by criminal justice authorities in order to stay off drugs and out of trouble. In contrast, proponents of a thoroughgoing public health perspective commonly argue that clients perform better if they are left alone to develop an effective therapeutic alliance with counselors. Both may be correct, but with respect to different groups of offenders. One approach has shown consistent promise for reducing drug use and criminal recidivism: an integrated public health-public safety strategy that combines community-based drug abuse treatment with ongoing criminal justice supervision. This article presents promising findings from programs implementing this strategy and discusses best treatment practices to meet the needs of both low-risk and high-risk clients.     

Civil legal needs of individuals in drug treatment

This report describes the findings of a pilot study that examined 17 domains of civil legal problems among individuals in drug treatment in one urban setting, the extent to which they seek help to resolve a potential legal problem, and their reasons for not seeking legal assistance. More than half the participants reported at least one legal problem related to health care and/or work, and nearly half reported legal problems related to their family, civil liberties, and/or neighborhood/community concerns. Less than one in five, however, sought legal assistance for problems in the five top-ranked domains, with the exception of family problems. The primary reasons for not seeking assistance were a lack of awareness that a problem was a legal issue and/or uncertainty about who could help. While preliminary in nature, the pilot study suggests that a significant proportion of treatment clients have civil legal problems and that treatment programs could help clients identify legal problems and resources for assistance.     

Racial disparities in substance abuse treatment and the ecological fallacy

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.     

The Intervention Approach to Drunk Driver Rehabilitation. Part I. Its Evolution,Operations, and Impact

In the campaign against drunk driving, the “third-generation” Weekend Intervention Program (WIP) met its clinical goals and was superior to education and treatment programs when treating DWI recidivists. Even in the face of the harsher legal climate in the case of WIP, this new intervention approach produced a lower recidivism rate than the control group. These positive findings suggest the need for further research with larger cell samples.     

Characteristics of criminal justice and noncriminal justice clients receiving treatment for substance abuse

This study compared three groups of substance abuse clients drawn from a representative sample of community treatment facilities in a large metropolitan area. Clients mandated to treatment from the criminal justice system (CJ-mandated; n = 124), clients currently involved with the criminal justice system but whose treatment was not legally mandated (CJ contact; n = 77), and clients who had no current criminal justice contact (no-CJ contact; n = 364) were compared with respect to sociodemographic and psychosocial characteristics including prior history of drug treatment and criminal justice system involvement, criminal behavior, psychological and physical health status, and treatment-related beliefs (e.g., motivation). The three groups differed from one another in certain respects; nonmandated clients currently in contact with the justice system showed similarities to other voluntary clients as well as to clients mandated to receive treatment. Implications for treatment are discussed.     

A prospective study of treatment outcome with a group of male problem drinkers

The present study was a follow-up of a group of young male problem drinkers (N = 96) presenting to a community-based treatment facility. Clients were assessed before and a minimum of twelve months after a set of brief treatment programs using a number of drinking- and nondrinking-related measures of functioning and corroborative information from a collateral. Regular contact was maintained with clients and collaterals throughout the follow-up period. Follow-up assessment data were available for 80 (83.3%) clients and collateral information for 84 (88%) clients. There were no significant differences found at follow-up between treatments used. There were, however, significant improvements evident on all measures of functioning in the total client group. Using stepwise discriminant analyses, clients classified as problem drinkers at follow-up were found to have higher scores on indices of problem drinking (including alcohol consumption, blackouts and legal charges) at their pretreatment assessment. Multiple regression analyses revealed that the best pretreatment predictors of client functioning at follow-up were measures of alcohol-related problems (accidents, jail, hangovers, morning drinking and deterioration). Factors limiting the interpretability and generalizability of these findings are discussed with particular reference to sample size and idiosyncrasies.     

Therapeutic community treatment for substance abusers with antisocial personality disorder.

This study compared treatment outcomes of substance abusers with and without antisocial personality disorder (APD) randomly assigned to two therapeutic communities, differing primarily in length of inpatient and outpatient treatment. We hypothesized that APD clients would be less likely to complete treatment, more likely to test positive for drugs and recidivate at follow-up, and that APD clients in the Standard program would have more favorable outcomes than those in the Abbreviated Inpatient program, because of the Standard program's longer inpatient treatment. Self-reports and objective measures of criminal activity and substance abuse were collected at pre- and posttreatment interviews. APD clients were as likely to complete treatment as other clients, and they exhibited the same patterns of reduced drug use and recidivism as did non-APD clients. Treatment program attended was unrelated to outcomes. Substance abusers diagnosed with APD can benefit from treatment in a therapeutic community combined with outpatient care.     

Integrating the therapeutic community and work release for drug-involved offenders: The CREST program

As the nation's first therapeutic community (TC) and work release center for drug involved offenders, CREST combines the basic elements of both modalities into an effective agent for behavioral change. This article explores the ways in which these elements are integrated and applied, and the outcome of such treatment as determined by subsequent substance abuse and criminal activity. Clients entering the program from prison progress through several phases of counseling, group interaction, confrontation, and education before they enter the work release phase, where they gain realistic experience and can implement what they learned in the TC concerning living drug free. Follow-up data collected at 6 and 18 months after entry into the program indicate that CREST clients have significantly lower relapse and recidivism rates than a comparable comparison group. CREST has similar effects on relapse and recidivism across sexes, racial/ethnic groups, and different age categories, although length of time in treatment and whether clients graduated do impact outcome variables.     

Effectiveness of a stand-alone aftercare program for drug-involved offenders

A study was made of the effectiveness of an aftercare program operating in conjunction with area outpatient drug free treatment programs while organizationally independent of those programs. Parolees and probationers mandated to treatment were assigned to aftercare on the basis of residence in the catchment areas in which aftercare facilities were located (n = 32) and randomly to aftercare (n = 62) and control (n = 51) when not a resident in a catchment area. No outcome differences were found between aftercare groups based on proximity to facility. At 6 months postbaseline the combined aftercare group showed significantly lower levels of criminal activity and frequent drug use as compared to controls. At 12 months postbaseline there was an attenuation of group differences with only tendencies toward significance obtained for lower levels of frequent drug use by the aftercare group. The findings are discussed in terms of the relevance of community variables for programming and for understanding long-term treatment outcomes.     

Employment and work among drug court clients: 12-month outcomes

Employment contributes to drug abuse treatment success and is an important treatment outcome (Institute of Medicine, 1990). However, few tailored employment interventions are available. This project developed an employment intervention focused on obtaining, maintaining, and upgrading employment. The current study, approved by an IRB, uses 12-month outcomes to examine intervention dosage effects. Participants were 500 clients who entered two Kentucky drug court programs between March 2000 and November 2002. Measures included demographics, drug/alcohol use, criminality, employment, and education measures from the Addiction Severity Index (McLellan, Luborsky, Woody, and O'Brien, 1980) as well as specific employment measures. To examine the intervention, the number of intervention upgrading sessions attended was divided by the number of possible upgrading sessions. Session attendance percentages were then used to median split into a low upgrading group and a high upgrading group and were compared with the no intervention group. These three groups were used in a series of ANOVA and chi-square analyses to examine differences at 12-month follow-up. When employment, legal work, illegal work, and employment problems were examined for one year and 30 days at follow-up, there were significant effects for jobs in the past year, days worked at a legitimate job in both the past year as well as 30 days, and income from a legitimate job in the past year. Participants in the high upgrade group received maximum employment benefits. Since legal earnings increased and illegal earnings decreased, drug-user treatment programs and practitioners should assess and refer clients to employment interventions. Tailored employment interventions should be tested to keep drug users in treatment and to increase treatment outcome. The study's limitations are noted and future needed research is suggested.     

Delivery of HIV risk-reduction services in drug treatment programs

This study examined services received for HIV risk reduction among individuals in drug treatment. Analyses were conducted using data from 4,412 participants in the national Drug Abuse Treatment Outcome Study (DATOS), a prospective multisite study of drug treatment effectiveness. A higher percentage of individuals in long-term residential programs received HIV-related services, compared with clients in short-term inpatient, methadone maintenance, and outpatient drug-free programs. More men than women, and individuals at higher sex-risk as compared with those at lower sex-risk, received HIV services. Logistic regression analyses indicated that individuals who engaged in sex work had a higher likelihood than those who did not, of receiving HIV-related services, although individuals with high-risk or multiple sexual partners were no more likely than others to receive HIV services. More comprehensive service delivery is needed in order to reduce the risk for HIV among clients in drug treatment.     

Effects of exercise-focused versus weight-focused maintenance programs on the management of obesity.

This study examined the effects of two maintenance programs on exercise participation, energy expenditure, energy consumption, and weight change in 67 obese adults undergoing behavioral weight-loss treatment. Following an initial 6-month treatment phase which produced a mean weight loss of 8.8 kg, participants were assigned randomly to an exercise-focused maintenance program or to a weight-focused maintenance program. Both maintenance programs included 6 months of biweekly group sessions. The exercise-focused program included supervised group walking sessions, individual and group contingencies for exercise completion, and relapse prevention training targeted specifically at the maintenance of physical activity. The weight-focused program contained a general focus on the maintenance of weight-loss through therapist-led group problem-solving of weight-related problems presented by individual participants. At the completion of the maintenance program and at long-term follow-up, there were no significant differences between conditions in exercise participation or energy expenditure. However, during the year following initial treatment, participants in the weight-focused program demonstrated significantly greater reductions in fat consumption and significantly better maintenance of weight losses than subjects in the exercise-focused program.     

Reflections on LSD – Ten Years Later

Abstract

An increasing number of individuals are being referred to alcohol treatment programs under coercion from the criminal justice system. While a substantial number of investigations have addressed coercive treatment for illicit drug-related offenses, fewer studies have focused on mandated treatment for alcohol-related problems. This article examines the treatment of two subgroups of clients coerced into alcohol treatment from criminal justice institutions. The article begins with an overview of the literature on clients coerced into treatment as a result of “driving under the influence” (DUI) charges. The characteristics of a subgroup that has received less attention are then described: lower socioeconomic clients who are coerced into alcohol treatment from the courts for non-DUI offenses, such as public inebriation, disorderly conduct, trespassing, assault, and theft. This subgroup of non-DUI coerced-treatment offenders depends primarily upon underfunded public services, although their treatment requires careful assessment and triage for multiple problem areas. The article addresses some potential political and economic roadblocks to comprehensive treatment and closes with questions and recommendations for further research.     

Employment and Work Among Drug Court Clients: 12-Month Outcomes

Employment contributes to drug abuse treatment success and is an important treatment outcome (). However, few tailored employment interventions are available. This project developed an employment intervention focused on obtaining, maintaining, and upgrading employment. The current study, approved by an IRB, uses 12-month outcomes to examine intervention dosage effects. Participants were 500 clients who entered two Kentucky drug court programs between March 2000 and November 2002. Measures included demographics, drug/alcohol use, criminality, employment, and education measures from the Addiction Severity Index () as well as specific employment measures. To examine the intervention, the number of intervention upgrading sessions attended was divided by the number of possible upgrading sessions. Session attendance percentages were then used to median split into a low upgrading group and a high upgrading group and were compared with the no intervention group. These three groups were used in a series of ANOVA and chi-square analyses to examine differences at 12-month follow-up. When employment, legal work, illegal work, and employment problems were examined for one year and 30 days at follow-up, there were significant effects for jobs in the past year, days worked at a legitimate job in both the past year as well as 30 days, and income from a legitimate job in the past year. Participants in the high upgrade group received maximum employment benefits. Since legal earnings increased and illegal earnings decreased, drug-user treatment programs and practitioners should assess and refer clients to employment interventions. Tailored employment interventions should be tested to keep drug users in treatment and to increase treatment outcome. The study's limitations are noted and future needed research is suggested. The study was funded by the National Institute on Drug Abuse.     

Long-term follow-up (3–4 years) of treatment for smoking reduction

The present paper reports the 3- and 4-year follow-ups of two smoking reduction clinics (n = 103) employing a comprehensive, non-aversive, behavioral treatment using stimulus control and self-control techniques. Most of the data were gathered via phone contact, while some clients were interviewed in person with corroborative carbon monoxide measurements taken at that time. While the general findings were similar to those reported for other long-term follow-ups of smoking programs, unlike earlier-reports, the overwhelming majority of subjects were contacted (an average of 90% for all follow-up periods). The average percentage of baseline for smoking subjects was equal to 56% and average percentage abstinent equal to 24% at final follow-up. Data are also presented which suggest greater attention be paid to the potential efficacy of controlled smoking when assessing the effectiveness of smoking reduction programs.     

Psychosocial Interventions for Adults with Severe Mental Illnesses and Co-Occurring Substance Use Disorders

Abstract

A growing body of research supports the effectiveness of integrated treatment for people with co-occurring severe mental illness and substance use disorders (dual disorders), but the effects of specific interventions are less clear. This review focuses on the effects of specific psychosocial interventions for dual disorders, including individual, group, and family modalities, as well as structural (e.g., case management model), procedural (e.g., contingency management), residential, and rehabilitation (e.g., vocational) interventions, with an emphasis on randomized controlled trials. Controlled research on specific individual interventions has focused mainly on motivation enhancement approaches for clients in the earlier stages of treatment, and has reported improved retention in treatment and substance abuse outcomes. Group interventions have been most extensively studied, with findings indicating that a variety of different treatment approaches specifically designed for dual disorder clients (e.g., emphasizing education, motivational enhancement, cognitive-behavioral counseling) are more effective at improving substance abuse outcomes than no group treatment or standard 12-Step approaches. Structural studies suggest that increasing the intensity of integrated dual disorder treatment produces only modest benefits. Residential dual disorder programs show great promise, especially for clients who are homeless and without psychosocial supports. Research on family therapy, procedural interventions, or rehabilitation is too premature at this time to draw any conclusions, although promising results have emerged in each area. Future avenues for research on specific interventions for dual disorders are considered.     

Users of free treatment slots at a community-based methadone maintenance clinic

At a community-based methadone clinic in Seattle, WA, 360 opiate-addicted individuals were enrolled in a treatment demonstration project. The treatment slots were free to clients and, unlike other funded treatment slots, did not require proof of eligibility based on documentation of indigence. The clients were compared with 70 clients enrolled in a research project begun 2 years earlier in which the sample was drawn from a population using normal funding sources at the same program. Subjects in the later demonstration project were older and had fewer years of education. A higher percentage of the demonstration project subjects were African American. These differences indicate that introduction of free treatment opened opportunities to individuals who have difficulty accessing treatment under normal circumstances. Subjects in the treatment demonstration project were more likely to have obtained needles from legal sources and used bleach to clean needles. These findings probably reflect the impact of needle exchange and outreach programs, established in the year prior to the demonstration project.     

Opening the black box. The impact of inpatient treatment services on client outcomes

This study examined the effects of specific services provided in therapeutic communities (TCs) to treatment outcomes. Findings are compared to prior analyses of treatment outcomes from the District of Columbia Treatment Initiative (DCI) that did not utilize the treatment service information. A subsample of DCI clients randomly assigned to two TC programs, who had remained in inpatient treatment for at least 60 days, were included in the analyses (n = 371). Logistic regression results illustrated that the level of vocational education services received was positively associated with completing treatment, and participation in group services was associated with decreases in postdischarge arrest. In addition, clients who received a greater number of all inpatient services were more likely to complete treatment and were less likely to be arrested after discharge. Findings suggest that TC programs should consider offering more vocational education and group treatment services to enhance prosocial behavior following treatment discharge.     

Women in Drug Abuse Treatment Programs: Factors That Influence Retention at Very Early and Later Stages in Two Treatment Modalities. A Summary

A preliminary study of factors associated with incorporation into the program and retention during the first 4 months of treatment among women entering mixed-sex and all-women demonstration drug abuse treatment programs. Prostitution, parents’ deviance, and entering while under legal jeopardy are among the more important characteristics of women less likely to stay in treatment, although these vary across different programs? One relatively small demonstration therapeutic community proved exceptionally able to retain more difficult clients.