Elements of an Effective Substance Abuse Treatment Model for Offenders

1. Elements of an Effective Substance Abuse Treatment Model for Offenders Correctional Service of Canada’s Model

2. Overview Research-based Offender Treatment • Part I: Effective Intervention • Substance use and abuse • Components of Effective Substance Abuse Interventions • Part III: Effective Programming • Components of Effective Substance Abuse Programs • Overview of CSC’s Substance Abuse Programs • Part IV: Maintenance and Aftercare • Principles of Relapse Prevention • Factors to consider • Part VI: Service Quality and Monitoring • Program Management

3. Research Based Offender Treatment (Part I) Effective Intervention • Substance Abuse: Stages of Acquisition & Intervention • Models and implications for treatment • Principles of Effective Intervention • Best practices in intervention

4. Substance Abuse:Stages of Acquisition & Intervention Initial Abstinence First Experimentation Non-problematic Substance Use Substance Use Substance Dependence Treatment Primary Prevention Secondary Prevention

5. Models and Implications for Treatment • The way substance abuse is understood influences the mode of intervention, e.g., Brickman’s Model

6. Substance Abuse:Brickman’s Model

7. Models and Implications for Treatment Selection of an over-arching approach to intervention based on: • Principles of effective correctional intervention • Best practices literature

8. Principles of Effective Correctional Programs Andrews (2000) Principles • Intervention based on a psychological theory of criminal behaviour that includes a general personality and social learning approach • Introduce human service strategies – do not rely on principles of retribution, restorative justice, deterrence or incarceration • Community-based services are preferred • Match intensity of intervention to level of risk

9. Principles of Effective Correctional Programs • Target known criminogenic need – multimodal is best, i.e., multi-need • Assessment of risk and need must be based on reliable and valid tools • Address responsivity and strength factors • Must include aftercare • Develop individualized plans • Integrity of program implementation and delivery • Attend to staff, managers and the broader social context

10. Summary of Best Practices* Treatment with support: • Pharmacological intervention has a role – with conditions and requires treatment • Behavioural relapse prevention programs • Community reinforcement • Martial therapy • Social skills training • Stress management • *Health Canada (1999) Best Practices: Substance Abuse treatment and rehabilitation

11. Best Practices Summary Effective Treatment Factors: • Programming matching is needed • Treatment should be in a group format unless contraindicated • Outpatient treatment is cost-effective • Brief interventions only with stable individuals with low to moderate problems • Treatment effect enhanced by competent service providers

12. Best Practices Summary Intervention with Specialized Groups • Some evidence for the efficacy of mandated treatment • Insufficient evidence to support provision of specific types of interventions to women • Adolescents need flexible approaches • Seniors benefit from community-based treatments • Integrate services for dually diagnosed individuals

13. Effective Intervention Operationalising “what works” • Substance use falls along a continuum • The intensity of the intervention matches severity of problem • Create and mobilize community-based resources for primary and secondary interventions • Cognitive-behavioural models integrating relapse prevention are effective models of treatment • Provide group interventions • Include harm reduction strategies • Ensure integrity in program delivery and management

14. Research-based Intervention for Offenders – Part III Elements of Effective Programming • Empirically supported model • Effective methods for intervention • Multimodal approach to intervention • CSC’s Substance Abuse Programs

15. Empirically Supported Model Cognitive-Behavioural Model • Addictive behaviours are as a result of the interaction between biological, psychological and sociocultural factors • Addictive behaviours are maladaptive because they are the central or sole means to feel pleasure and to deal with life’s demands • Changing behaviour and thinking will modify existing patterns Relapse Prevention • Most people don’t successfully change behaviour on first effort • Individuals identify their risk factors and broaden ways to cope in order to decrease likelihood of lapsing or relapsing into old patterns

16. Effective Methods The intervention is most effective when it is: • Structured • Has built in reinforcement, modelling and skills acquisition through role-plays, graduated approximations and extinction • Responsivity factors are identified and addressed

17. Effective Methods • Same processes that maintain substance abusing behaviours are used in treatment to change patterns (Reinforcement, modelling , skill acquisition through role-play and graduated approximations, cognitive restructuring) • Motivational enhancement strategies • Harm reduction model

18. Assertion training Social skills training Problem solving Controlled drinking strategies Methadone maintenance Employment training Recognition of high risk situations Relapse prevention Behavioural self-control Stress management Marital Aftercare Multi-modal Interventions

19. CSC’s Integrated Model of Change • Psychology of Criminal Conduct (Andrews & Bonta) • Social Cognitive Theory (Bandura) • Cognitive Behavioural • Relapse Prevention Therapy (Parks & Marlatt) • Coping Model of Criminal Recidivism (Zamble & Quinsey) • Transtheoretical Model of Change

20. Integrated Model • Crime because learning and skills deficits • Substance abuse because of learning, dependency and deficits Beh’r is maintained by past learning, including peer modeling, reinforcement contingencies, cognitive expectations, and biological influences • Substance abuse and crime linked • Change patterns of substance abuse to decrease relapse and recidivism • Motivational enhancement necessary to facilitate change

21. CSC’s National Substance Abuse Programs (NSAP) • There are three levels of program intensity to address differing severity of problem – high, moderate and low • Programming starts at the beginning of the sentence, where warranted • Aftercare is mandatory

22. Program Timing M A I N T E N A N C E Pre- Release Booster M A I N T E N A N C E NSAP High NSAP Mod NSAP low

23. Menu of Programs

24. CSC’s application of Effective Program Methods • Programs are structured with a “scripted” manual for facilitators to follow • Programs based on the principles of adult learning • Offenders guided to see personal relevance of the content • All skills are introduced, modelled and reinforced and frequently practiced • Facilitators sensitised to responsivity factors and given guidance to address

25. Skills in CSC’s Programs • Self-control training: self-monitoring, goal setting, • Identification of high risk situations • Problem solving to deal with triggers • Relapse prevention strategies to manage triggers • Cognitive coping: ABC model to identify risky thinking and beliefs, to counter outcome expectancies; inoculation to come up with positive coping thoughts • Behavioural coping: • Craving management • Intrapersonal control: time out, counting down, breathing techniques • Social skills: listening, receiving feedback, assertion, negotiation, dealing with pressure, asking for help, expressing negative feelings, conflict management, empathy building, perspective taking and community building

26. Self Monitoring + Assessment Efficacy Enhancing Imagery + Emotional Regulation Limit use + Slip Management Where it fits Decreased Self Efficacy + POE Violation Effect High Risk Situation Ineffective Coping LAPSE Competency Assessment + Skills Training + Relapse Prevention Rehearsal Decision Matrix + Lt vs ST Effects Analysis of Relapses Emergency Relapse Plan Cognitive Restructuring

27. Program Phases • All NSAP intensities have same phases • Phase I: Deciding What I would Like to Change • Phase II: Improving the Odds • Phase III: Learning the tools for Change • Phase IV: Using the Skills and Planning for my Future

28. Phase I • Goal is to illustrate how participants became dependent upon substances, how it is connected with their criminal behaviour and the consequences of this across all life domains • Personal goal setting • Identification of obstacles and self-management deficiencies • Self-monitoring • POE related to crime and drugs • basic social and intrapersonal skills • Coping with cravings and urges

29. Phase II • Goal is to have participants recognise their internal and external risk factors • Use Inventory of Drug/Drinking Situations to identify HRS • Marlatt’s model of Relapse Prevention • How triggers effect them (T-D-G) and how they build (G-Y-R) • Development of integrated crime and substance abuse cycles • Problem solving steps to disrupt the cycles

30. Phase III • Learning Coping by Thinking and Coping by Doing skills to create a different life (4 key life areas) • Using Cognitive and Behavioural Coping to develop • Better relationships: intimate partners, friends, others authority • Feeling good – enhancing sense of self, emotion management, mental health • Personal control and freedom – putting in place things to stop the return to substance misuse • Satisfying life

31. Phase IV • Goal is to finalize the recidivism and relapse prevention plans • Development of life area plans for: substance use, work/school/finance, relationships, leisure, legal, health and well-being, and community building • Evaluate RP and life area plans • Set goals for continued change and monitoring

32. Research Based Offender Treatment – Part IV • Maintenance and Aftercare • Why Maintenance

33. Maintenance • Research supports that aftercare maximizes effectiveness • Maintenance reinforces and strengthens progress made in treatment – reflects the principles of relapse prevention

34. Maintenance Factors to consider: • Frequency of contact based on stability and functioning – external monitoring function • Relevant for current life circumstances • Evaluation and enhancement of skill set

35. Maintenance CSC’s aftercare for offenders with substance abuse problems: • Institutional Substance Abuse Maintenance Program • Pre-Release Boosters • Community Substance Abuse Maintenance Program • Community Maintenance Program

36. Research-based Offender Treatment – Part VI Service Quality and Monitoring • Program Management • Considerations for successful implementation • Staff Training and Quality Assurance • Research and Evaluation • Accreditation of Programs

37. Program Management Considerations for successful program implementation • Sincere motivation • Support at the top • Staff competence • Cost-benefit surplus • Clarity of goals and procedures • Clear lines of authority • Implementation evaluation • Program evaluation framework

38. Program Management • What to evaluate • Direction. Requires strategic planning, mission statement with corresponding policy, clear goals and objectives • Existing conditions • Application of the principles of matching • Implementation of appropriate intervention • Therapeutic integrity • Evaluation of staff

39. Program Management Staff Training and Quality Assurance • Staff selection is critical • Well trained, supervised and supported staff are necessary • CSC’s infrastructure includes National, Regional, and local management • Program manual and staff training manual for consistency • Program deliverers are monitored for compliance and efficacy, when warranted they are certified, and have ongoing follow-up

40. Program Management Research and Evaluation • Program evaluation is necessary to assess efficacy, cost-effectiveness and inform ongoing program development • Evaluation commenced immediately upon implementation

41. Outcome Data CSC’s original programs • Offenders who completed high intensity program demonstrated a 19% reduction in readmission and a 50% reduction in new convictions • High intensity program participants were less likely to be readmitted (37% vs. 45%) to custody and were slightly less likely to have their conditional release revoked as a result of a new offence (4% vs. 8%).

42. Outcome data • Offenders completed the moderate intensity intervention and showed a 14% reduction in re-admission (from 49% to 42%) and 31% reduction in new convictions (from 21.9% to 15.2%) • Offenders, who completed the low intensity, plus maintenance, had a 29% reduction in readmission. • There was a 56% reduction in re-convictions for those who completed maintenance.

43. Program Management • Unit costs for high, moderate, low and maintenance intervention • High - $6,758 • Moderate – $1,100 • $Low – $900 • $Maintenance - $364 • Unit costs of in-patient treatment • $12, 079 • Preliminary data support cost effectiveness of intervention

44. Program Management Accreditation of Programs • International panel reviews to ensure that new programs meet highest standards • NSAP accredited in December 2003 • 8 criteria: explicit, empirically-based model of change, targets criminogenic needs, uses effective methods, is skills oriented, addresses responsivity factors, intensity related to severity of problem, offers continuity of care, and has ongoing monitoring and evaluation • Afterinitial accreditation, programs are on a 5 year cycle