Transcript The Criminal Drug User Changing Behavior

In Custody Treatment
Rationale, Outcomes and
Directions
David A. Deitch, PhD
Professor of Clinical Psychiatry
University of California, San Diego
Addiction Training Center
Let’s start with some bad news
Type of Offense (June, 1997)
5.6
5.9
2.6
3.4
0.7
60.2
9.6
Drug Offenses
Extortion
Immigration
Robbery
Property Offenses
White Collars
Firearms, Explosives
Violent
Illegal Drug Use Detected (UA+) Among
Male Arrestees (in 23 Cities)*
100
% Any Drug
% Cocaine
80
60
40
66
59
62
63
65
42
43
43
42
39
68
66
66
65
39
36
36
35
20
0
1991 1992
1993 1994
1995 1996 1997
1998 1999
*Based on original 23 DUF cities; 1999 data for St. Louis not available.
Drug Arrests By Decade
(FBI Crime Reports)
70%
63.7%
54.2%
60%
50%
36.9%
40%
30%
20%
7.9%
10%
0.7%
0.3%
0%
1941-50
1951-60
1961-70
1971-80
1981-90
1990-1999
State & Federal Inmates Needing vs
Receiving Substance Abuse Treatment
(X 1000)
Need Trt
900
Rec'd Trt
749
800
688
700
600
840
801
627
587
552
500
400
300
200
74
107
121
150
130
168
149
100
0
1990
1991
1992
1993
1994
1995
1996
Nationwide cost
Columbia University Report, March 2003
$ 30 billion states spent on adult corrections
(incarceration, probation, parole)
$24.1 billion of it was on substance involved
offenders
On Women…
During the 1980s and 1990s, the number
of incarcerated women tripled, while
the number of men doubled.
80% of these women have substance
abuse problems.)
Sources: “What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000
Lifetime Chances of Going to Prison
30
28.5
25
20
15
16.2
10
5
4.4
0
3.6
0.5
White
Black
Men
1.5
Hispanic
Women
BJS 2003
The Rise of Prison and Jail Populations
Average Annual percent change
9
8
7
6
5
4
3
2
1
0
8.6
7
5.6
4.4
0.4
Federal Prisons
State Prisons
1999-2000
2000-2001
1.6
Local Jails
New Court Commitments Per 1,000
Arrests- Violent Offenses
800
700
700
600
500
400
460
300
365
229 266
200
233
100
56 78
0
Murder
Forcible Rape
1990
Robbery
2000
Aggravated
assault
Property Offenses
200
193
180
160
160
140
120
100
103
80
60
72
71
79
77
40
20
24
34
28
0
Burglary
Larceny/theft Motor vehical Drug abuse
theft
violations
1990
2000
Weapons
violations
Parole Violators
Returned to State Prisons
All
Year
2001
New Court
Admissions
Commitments
586,273
360,251
Parole
Violations
209,636
Recent Change
19902001
27%
11%
57%
Why Incarceration Does Not Shape
Behavior?
We want them to have self-worth
So we destroy their self worth
We want them to be responsible
So we take away all responsibility
We want them to be positive and constructive
So we degrade them and make them useless
We want them to be trustworthy
So we put them where there is no trust
We want them to quit exploiting us
So we put them where they exploit each other
We want them to be non-violent
So we put them where violence is all around
them
We want them to quit being the tough guy
So we put them where the tough guy is
respected
We want them to quit hanging around losers
So we put all the losers in the state under one
roof
Common wisdom says that when
you discover you are riding a dead
horse, the best strategy is to
dismount. However, we often try
other strategies, including the
following:
• Buy a stronger whip.
• Change riders
• Say things like “This is the way we always have ridden
this horse.”
• Appoint a committee to study the horse.
• Arrange to visit other sites to see how they ride dead
horses.
• Create a training session to increase our riding ability.
• Harness several dead horses together for increased speed.
• Declare that “No horse is too dead to beat.”
• Provide additional funding to increase the horse’s
performance.
• Declare the horse is “better, faster, and cheaper” dead.
• Study alternative uses for dead horses.
• Promote the dead horse to a supervisory position.
Time for some better news
Three very important questions
• Is substance abuse treatment effective?
• What constitutes a successful treatment?
• How do we know it?
Social Criteria for Treatment Success
Dr. Jerome Jaffe
• Diminish crime in community
• Diminish tax consumptive behavior
• Diminish illicit substance abuse
• Increase tax productive behavior
• Increase personal well being
Criteria 1- Diminish crime in the
community
70
60
50
40
30
20
10
0
1 year before
Methadone Maintenance
1 year post
Therapeutic Community
5 years post
Outpatient drug free
Criteria 2 – Diminish illicit drug use
80
70
60
50
40
30
20
10
0
1 year before
1 year post
Outpatient Methadone
Residential (TC)
5 years post
Outpatient drug free
Criteria 3 & 4- Diminish tax consumptive
behavior (full time employment)
50
45
40
35
30
25
20
15
10
5
0
1 year before
1 year post
Outpatient Methadone
Residential (TC)
5 years post
Outpatient drug free
Criteria 5 – Increase Personal Well-Being
(Suicidal Indicators)
50
45
40
35
30
25
20
15
10
5
0
1 year before
1 year post
Outpatient Methadone
Residential (TC)
5 years post
Outpatient drug free
90-Day Retention in Long-Term Residential
Community Programs
by Treatment Readiness and Legal Pressure
100
Low Readiness
Moderate Readiness
High Readiness
80
51
60
38
40
46
54
34
27
20
0
No Legal Pressure
Legal Pressure
N=2194; Knight, Hiller, Broome, & Simpson, 2000 (JOR)
Probationer Response to Treatment
(% with Problems in Psychological Functioning)
35
Anxiety
Self-esteem
Depression
30
25
20
15
10
5
0
Intake
Mid-Treatment
At Discharge
N=259; Knight & Simpson, 1994, Annual Report on 1993 SATF Intakes
It appears that the profile of a
client in community based
therapeutic community is
very similar to the one of a
substance abusing offender in
custody
Key Issues
2 of every 3
Inmates have
Used drugs
Intensity Levels ?
Low
(education)
Problem
Severity?
Selection of
Treatment?
Moderate
(12-steps)
High
(modified TC)
Aftercare
• Engagement
• Performance
• Outcomes
Historical Overview of
Prison-Based Treatment Evaluations
80
74
Treatment
64
63
No treatment
60
41
40
27
29
26
28
20
0
% Arrested
(2+ Years)
Stay'n Out
% Imprisoned
(3 Years)
Cornerstone
% Jailed
(1 Year)
Amity
% Arrested
(18 Months)
Key-Crest
In: Orientation to Therapeutic Community, 1998, Mid-America ATTC
Delaware/Crest Program:
3-Year Re-Arrest & Drug Use Rates
% with New Arrests
% with Drug Use
95
83
71
73
72
65
45
31
No
Treatment
(n=210)
ITC
Dropout*
(n=109)
ITC, but no
Aftercare*
(n=101)
ITC +
Aftercare*
(n=69)
Martin, Butzin, Saum, & Inciardi, 1999 (The Prison Journal)
*p<.05
(adjusted
diff vs.
No Trt)
California/Amity Program:
3-Year Return-to-Custody Rates (%)
75
82
79
27
No
Treatment
(n=189)
ITC
Dropout
(n=73)
ITC, but no
ITC +
Aftercare Aftercare*
(n=154)
(n=162)
Wexler, Melnick, Lowe, & Peters, 1999 (The Prison Journal)
*p<.001
Texas/High-Severity Group:
3-Year Return-to-Custody Rates (%)
66
52
Year 3
Year 2
Year 1
16
12
32
30
10
No
Treatment
(n=58)
26
14
18
Aftercare
Dropouts
(n=101)
11
1
Aftercare
Completers*
(n=123)
Knight, Simpson, & Hiller, 1999 (The Prison Journal)
*p<.01
Texas/New Offenses Only:
3-Year Return-to-Custody Rates (%)
22
19
6
No
Treatment
Aftercare
Dropouts
Aftercare
Completers
Knight, Simpson, & Hiller, 1999 (The Prison Journal)
Evidence-Based Treatment Model
Induction
needed?
Motiv
Aftercare
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Inmate
Attributes
Supportive
Networks
Sufficient
Retention
Therapeutic Psycho-Social
Relationship
Change
Drug
Use
Crime
Social
Relations
Posttreatment
Simpson, 2001 (Addiction)
Problems at Treatment Admission
(TCU Self-Ratings at Intake in 1996)
26
Self-esteem
30
Depression
42
Anxiety
39
Childhood
Changes
over
time?
57
Risk-taking
27
Hostility
Trt Readiness
20
% of Probationers
N=409; Dees, Pitre, & Dansereau, 1997, Annual Report on 1996 Intakes
Hostility and Treatment Dropout Rates
(% with high Hostility scores [4+ on 1-7 scale])
60
52
50
50
Dropouts (N=97/58)
Completers (n=290)
40
30
20
29
25
26
24
21
10
Intake
Month 1
Month 3
Month 6
N=399; Broome et al., 2000, ACJS Conf Presentation (New Orleans)
Predictors of Early Engagement
Age
Female
Alcohol Prob
Coc Prob
Background
Characteristics
Self
Efficacy
+
Anxiety
-
+
Hostility
-
Desire
for Help
+
Psychosocial
Functioning at Intake
Personal
Involvement
Personal
Progress
Trust in
Staff
Client Ratings
at Month 1
N=399 ; Hiller et al., in progress, 1998 Wilmer admissions
Multivariate Model of Early
Dropout
(Stepwise Logistic Regression)
Psychosocial
Low Self-efficacy
Odds Ratio=1.5
Background
High Risk
Odds Ratio=2.6
Unemployed
Odds Ratio=2.1
Early
Dropout
N=339; Hiller, Knight, & Simpson, 1999 (The Prison Journal)
Multi-Site Predictors of
Recidivism
Younger Age
Previous Arrests
Recidivism
ASP/Hostility
Childhood Problems
Motivational
Readiness
Aftercare
Completion
Trt Satisfaction
Strongest
Predictors
Hiller et al., 1999 (Addiction); Wexler et al., 1999 (CJB)
Male New Admissions to Prison
by Type of Offense
w ith Tx Bed Grow th
16000
14000
Total # of
Tx Beds
12000
Drugs
10000
8000
Property
6000
Person
4000
2000
Other
0
1997
1998
1999
2000
2001
YEAR
R.Krupp – CDC-OSAP, in press. 3/03
2002
Female New Admissions to Prison
by Type of Offense
with Tx Bed Growth
Total # of Tx 3000
Beds
2500
Property
2000
1500
Drugs
*
Person
1000
Other
500
0
1997
1998
1999
Y ear
2000
R.Krupp – CDC-OSAP, in press. 3/03
2001
Does In-Custody Therapeutic
Community Have Any Impact On
Custody Staff?
Let’s find out
Inmate Rules Violation Reports
(115’s)
408
322
265
166
67
Violence/Threat of
Violence
101
Non-violent Disruptive
Behavior
79
Failure to Program
General Population
61
Grooming Standards
Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al.
Inmate Rules Violation Reports
(115’s)
1273
511
Serious 115's
General Population
Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Use/Possession of
Controlled Substances
• 45-50% of SAP inmates tested monthly
• Total u/a’s from April 1998 to March 2000:
15,221
• Total positive u/a’s:
24
• % of positive test results:
0.15%
National average is 4.8% (Camp&Camp, 2000)
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Sick Related Absenteeism
(Sick Calls)
1234
522
General Population
Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Occupational Injuries
(Documented Worker’s Comp)
358
28
107
0
Related to Assaults
Not Related to Assaults
General Population
Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
35
Effects of Treatment Environment on Custody
Staff: Perception of Health
30
25
20
15
10
5
0
Excellent
Very Good
General Pop.
Fair
Poor
Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Custody Staff - Perceptions of Job-related Stress
(SATF-SAP)
10
9
8
7
6
5
4
3
2
1
0
1
2
3
4
5
General Pop.
No Stress
6
7
Treatment
8
9
10
High Stress
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Treatment Benefits
for Correctional Staff
•
•
•
•
•
•
Greater job satisfaction
Improved working environment
Reduced job stress
Better physical and emotional health
Improved officer safety
Greater sense of accomplishment and
control
• Added inmate management tools
General Findings & Recommendations
•
Therapeutic Community appears to be the most
effective treatment model for in-custody settings.
–
–
–
•
Boot camps & periodic drug-focused counseling have
poor outcomes
Selective education, 12-step, cognitive-behavioral
therapies & programs that use agonists (such as
methadone) show promise
Risk assessments should guide selections for
treatment.
TC model is most effective for high-risk cases.
General Findings &
Recommendations (continued)
• Treatment works best if provided at end of
sentence – pre release.
• Treatment works best if in separate housing areas.
• Treatment works best with dedicated job
assignments.
• If use “lifers” or long sentence inmates, job pay
title is important.
• Engagement in transitional aftercare is crucial for
effectiveness.