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Substance Abuse Treatment in CJS: Integrative Models for Effective Change in the 21 st Century

Substance Abuse Treatment in CJS: Integrative Models for Effective Change in the 21 st Century. C. Wayne Kempske Lecture Series Alcohol and Drug Abuse Administration May 2, 2008. Faye S. Taxman, Ph.D. George Mason University ftaxman@gmu.edu. Criminal Justice. The 1980’s-1990’s.

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Substance Abuse Treatment in CJS: Integrative Models for Effective Change in the 21 st Century

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  1. Substance Abuse Treatment in CJS: Integrative Models for Effective Change in the 21st Century C. Wayne Kempske Lecture Series Alcohol and Drug Abuse Administration May 2, 2008 Faye S. Taxman, Ph.D. George Mason University ftaxman@gmu.edu

  2. Criminal Justice

  3. The 1980’s-1990’s

  4. Questions that Needed Answers • Do offenders deserve treatment? • Is coercedtreatment effective? • Should offenders be given a priority for treatment? • How can jails, prisons, probation/parole and pretrial work with treatment agencies?

  5. Identify Eligible Offenders Identify Eligible Offenders LEGEND = Criminal Justice Function = Treatment Function Screen & Select Eligible Offenders =Shared Criminal Justice and Treatment /EBP Conduct Criminal Justice Risk Assessment CJ/TreatmentDischarge Assign Risk Level Conduct Clinical Assessment Admit Client & Conduct Intake Procedures Develop Treatment Plan Administer Treatment CJ/Treatment Discharge ConductDrug Testing Determine Initial Treatment Level of Care Change TreatmentLevel of Care &/orSupervision Level Conduct Drug Testing Treatment Progress Change Treatment Level of Care &/or Supervision Level Apply GraduatedSanctions Select Treatment Provider Treatment orSupervisionNoncompliance Treatment or Supervision Noncompliance Apply Graduated Sanctions Select Treatment Provider Refer &/or Place Client in Treatment How Can Treatment Fit Within the CJS

  6. Today

  7. Sticking Points • What have we done? • How much worse can this population get? • How can we engage offenders in treatment ? • We have programs, what else do we need?

  8. Insatiable Appetite: The Ever Expanding Correctional Population: 8+M Adults, 650K Juveniles 424,046 adultsreceive tx (7.6%) 1:28 adults 5,613,739 adults need TX(4.5M males, 1.1M females) 253,034juveniles need TX(198,000 males, 54,000 females) 54,496juveniles GET tx (21.5%) *Bureau of Justice Statistics, 2005 adjusted with estimates from Taxman, et al, 2007.

  9. Substance Use Disorders (Percentages) CJ Populations have 4 times the SA Disorders as the General Population

  10. STDs(Percentages) Similar pattern with AIDS/HIV (2%CJ,<1%general) TB 25%CJ, .005%general, HEP C 30%CJ, 1.6%general

  11. Co-Occurring Disorders and Mental Health Disorders (Percentages)

  12. Addiction Treatment

  13. “Research to Practice” • Workforce Development & Skills • Quality Improvements • Financial Incentives/Contracting Cognitive Behavioral Therapy, Contingency Management, Motivational Enhancement Therapy, Manualized Txs Pharmotherapies

  14. NIATx: Quality Improvement Processes

  15. Number of Days to Assessment Hoffman, et al, in press

  16. Retention in Treatment after First Sessions Hoffman, et al, in press

  17. Financial Incentives • Maryland’s Performance Standards • >65% retained at least 90 days • >50% successful completion • Both standards = 100% performance payment • One standard = 50% performance payment

  18. Pay for Performance Incentive Breakdown

  19. Criminal Justice &Treatment

  20. What Has Been Tried? CJ Interventions Clinical Techniques • Education(Psycho-Social) • Non-Directive Counseling • Directive Counseling • Motivational Interviewing • Moral Reasoning • Emotional Skills • 12 Step with Curriculum • Cognitive Processing • Cognitive Behavioral (Social, Interpersonal, etc.) • Therapeutic Communities • Contingency Managements • Intensive Supervision • Boot Camp • Case Management • TASC • DTAP (Diversion to TX, 12 Month Residential) • Tx with Sanctions (e.g. Break the Cycle, Seamless System, etc.) • Drug Courts • In-Prison Tx (TC) with Aftercare

  21. Survey Methodology

  22. Response Rates from Survey • Survey administered via mail • Multi-level (Head of state agency, facility administrator, staff) Percent of Respondents • Analyses found that there was no difference in response by geography, size of jurisdiction/facility, or type of organization Taxman, Young, Wiersema, Rhodes, & Mitchell (2007). Journal of Substance Abuse Treatment.

  23. Offenders Who Need Treatment, Do Not Receive It

  24. Type of SA Services Offered • Few Offenders Can Access Services on Any Given Day • Majority are Drug-Alcohol Education • Adult Prison—74%, 8.8% ADP • Adult Jail—61%, 4.5% ADP • Adult CC—53.1%, 15.5% ADP • Juv Res—88%, 30%ADP • Juv CC—80.2%, 8.2ADP • Low Intensity OP (<4Hrs/Week) • CBT based therapies are reported to be provided in a third of the juvenile residential and adult prison programs; only 1 in 5 community based programs report use

  25. % of Adult ADP in Substance Abuse Treatment Services Estimates of Needs (Belenko & Peugh, 2005): Dependent: 31.5% Males, 52.3%Females % of ADP in SA Tx Services

  26. Percentage of Adult Offenders who Receive Needed Services

  27. Limited Use of Evidence-Based Practices

  28. Elements of Evidence-Based Practice (from Meta-Analysis & Expert Consensus Panels) Developmentally appropriate treatment Use of therapeutic community/CBT Standardized risk assessment Standardized substance abuse assessment Continuing care or aftercare Use of graduated sanctions and incentives Use of drug testing in treatment Systems integration Use of techniques to engage and retain clients in treatment Addressing co-occurring disorders Treatment duration of 90 days or longer Assessment of treatment outcomes Family involvement in treatment Availability of qualified treatment staff Comprehensive Services Created a Score Based on Availability (N/Y) Sources of EBPs: NIDA Principles of Drug Abuse Treatment for Criminal JusticePopulations Drug Strategies Bridging the Gap: A Guide to Drug Treatment in the Juvenile Justice System

  29. 4.7 Adult Community 5.6 Adult Prison 4.8 Juvenile Community 5.7 Juvenile Residential Prevalence of EBPs Reported by Correctional Administrators in National CJDATS Survey Mean EBP score Use Less Than 1/3 of Recommended EBPs % of Programs Reporting EBPs Friedmann, et al, (2007); Henderson et al. (2007). Journal of Substance Abuse Treatment.

  30. Tx Practices in “Practices” % Administrators Reporting Facility Use Juvenile & adult prisons are more likely to report the use of CBT treatments than facilities in community settings Taxman, Perdoni & Harrison, 2007; Young, Dembo, & Henderson, 2007

  31. Administrator & Organizational Characteristics Predict EBP Use

  32. Correctional Administrators: Treatment Directors: • Community based programs • Administrators: • - Background in human service • - Knowledge about EBP • - Belief in rehabilitation • Performance driven culture • Emphasis on training • Emphasis on internal support • Larger % of correctional population • Administrators • - Years in running programs • - Belief in importance of SA in • community • Accredited program Factors* Associated with the Use of EBPs in Adult Correctional & SA Treatment Programs • All factors listed were statistically significant in multivariate analyses. • Factors not impacting use of EBPs: Physical Plant, Staffing, Leadership Friedmann, Taxman, & Henderson, 2007

  33. Higher Scores Indicate Less Use Engagement, 90 Day Treatment Duration, Asst of Tx Outcomes Occur Together Drug Testing and Systems Integration Occur Together Henderson, Taxman, & Young (2008). Drug and Alcohol Dependence

  34. Integration Items with SA Agencies • More integration has been found to increase use of EBPs, more holistic services, and improved outcomes **p<.05

  35. Administrators Attitudes: Importance of Substance Abuse Treatment Relative to Education* Four Classes *Results include data from both juvenile and adult administrators Henderson & Taxman (Submitted). Drug and Alcohol Dependence.

  36. Structural Factors to Predict Higher Access Rates Organizational Learning Integration Taxman, Kitsansis, Perdoni, under review

  37. STATE Policy on INFLUENCE LOCAL SERVICE DELIVERY

  38. More EBPs when • State cohesive organizational culture • Local emphasis on quality treatment • At state level, shared activities between substance abuse treatment & probation and parole • State executives place a high priority on substance abuse treatment, despite local administrators’ punishment attitudes • More adequate staffing at state level strengthened the relationship between training and funding for new programs • When states had better physical facilities, stronger internal support for new programs

  39. Moving Ahead: Turning the Provider of Last Resort into a Service Provider

  40. What We Learned • Organizational Learning Needs to Occur Within and Across Organizations • Process Matters! • System Integration requires SA TX & CJS to create boundaryless processes at assessment, treatment placement, monitoring, and discharge • Family and support systems enhance treatment and CJS • CJS Actors Need to be Part of the TX Process & TX Actors Need to be Part of the Corrections Process

  41. Unintended Consequences: Our Current Tx & CJS Practices • With the majority of offenders in need of servicesand the minority receiving servicesCJS, TX providers, and offenders can not “feel” the impact of treatment • The continual failure to provide access to effective treatment services contributes to an offender’s disbelief and defiance • The mixed messages in the CJS (and TX system) about the value of treatment undermines recovery • Strides in SA treatment do not carry over into the CJS with the same, inappropriate processes and services • Motivational Engagement practices need to underscore both TX and CJS actions

  42. Impact: Perceived Fairness on Outcomes • When Offenders Believe they have a VOICE, reductions in negative outcomes occur! • Fairness Addresses Legal Cynicism PO:Procedural Justice -.19* Arrest/VOP -.23* -.31* Taxman & Thanner, 2004 Drug Use at Follow-up TX Providers: Procedural Justice -.44*

  43. Needs of the State of Maryland • Approximately 38,000 supervisees have orders for drug and/or alcohol treatment • 22643 referrals (47%) from CJS to SA Treatment (majority in OP services), including 1650 from drug court • Few offenders received tx in prison (<2000) or jails • How can treatment be expanded in MD? Correctional treatment?

  44. Making the 21st Century Count • Ensure that 50% of offenders are in SA TX at any given time • Correctional TX needs to be expanded to be holistic—SA, mental health, criminal thinking, vocational and literacy—and serve more offenders • CJS-TX Providers need to work seamlessly with shared, integrated processes • At the County level, more focus on interorganizational learning environments and processes to advance service delivery • Probation/Parole Officers-SA Tx Providers Need to Jointly Deliver Services • Offenders Need to be Involved in the Decisions about TX Placement, Consequences, and Other Services

  45. Shared Decision-Making: Key to Successful Outcomes • Change the environment to reinforce prosocial goals • Engages offender in change process • Active, rather than passive • Goal-oriented • Assigns “ownership” to the offender • Deportment & empowerment

  46. Embrace an Environment where Offenders Can Change Engage Change Reinforce

  47. The world is moving so fast these days that the man • who says it can't be done • is generally interrupted by someone doing it. • Harry Emerson Fosdick

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