in custody treatment rationale, outcomes and directions david a. deitch, phd professor of clinical...

In Custody Treatment Rationale, Outcomes and

Directions

David A. Deitch, PhDProfessor of Clinical Psychiatry

University of California, San DiegoAddiction Training Center

Let’s start with some bad news

Type of Offense (June, 1997)

0.73.4

9.0

9.6

60.2

5.65.9 2.6

Drug Offenses Robbery Firearms, Explosives

Extortion Property Offenses ViolentImmigration White Collars

Illegal Drug Use Detected (UA+) Among Male Arrestees (in 23 Cities)*

656666686563

59 6266

36 36 3542 43

39394243

0

20

40

60

80

100

1991 1992 1993 1994 1995 1996 1997 1998 1999

% Any Drug % Cocaine

*Based on original 23 DUF cities; 1999 data for St. Louis not available.

Drug Arrests By Decade(FBI Crime Reports)

0.3% 0.7%

7.9%

36.9%

54.2%

63.7%

0%

10%

20%

30%

40%

50%

60%

70%

1941-50 1951-60 1961-70 1971-80 1981-90 1990-1999

State & Federal Inmates Needing vs Receiving Substance Abuse Treatment

552

74

587

107

627

121

688

150

749

130

801

168

840

149

0

100

200

300

400

500

600

700

800

900

1990 1991 1992 1993 1994 1995 1996

Need Trt Rec'd Trt(X 1000)

Nationwide costColumbia University Report, March 2003

$ 30 billion states spent on adult corrections (incarceration, probation, parole)

$24.1 billion of it was on substance involved offenders

During the 1980s and 1990s, the numberof incarcerated women tripled, while the number of men doubled.

80% of these women have substance abuse problems.)

On Women…

Sources: “What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000

Lifetime Chances of Going to Prison

BJS 2003

4.40.5

28.5

3.6

16.2

1.5

0

5

10

15

20

25

30

White Black Hispanic

Men Women

The Rise of Prison and Jail Populations Average Annual percent change

8.6

7

5.6

0.4

4.4

1.6

01

23

45

67

89

Federal Prisons State Prisons Local Jails

1999-2000 2000-2001

New Court Commitments Per 1,000 Arrests- Violent Offenses

460

700

229 266 233

365

56 780

100

200

300

400

500

600

700

800

Murder Forcible Rape Robbery Aggravatedassault

1990 2000

Property Offenses

160

193

24 28

72 71

103

79

34

77

0

20

40

60

80

100

120

140

160

180

200

Burglary Larceny/theft Motor vehicaltheft

Drug abuseviolations

Weaponsviolations

1990 2000

Parole Violators Returned to State Prisons

All New Court ParoleYear Admissions Commitments Violations

2001 586,273 360,251 209,636

Recent Change

1990- 27% 11% 57%2001

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 usSo we put them where they exploit each other

We want them to be non-violentSo we put them where violence is all around

themWe 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 losersSo 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

Why not treat them?

Three very important questions

• Is substance abuse treatment effective?

• What constitutes a successful treatment?

• How do we know it?

Social Criteria for Treatment SuccessDr. 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

0

10

20

30

40

50

60

70

1 year before 1 year post 5 years post

Methadone Maintenance Therapeutic Community Outpatient drug free

Criteria 2 – Diminish illicit drug use

0

10

20

30

40

50

60

70

80


Outpatient Methadone Residential (TC) Outpatient drug free

Criteria 3 & 4- Diminish tax consumptive behavior (full time employment)

0

5

10

15

20

25

30

35

40

45

50



Criteria 5 – Increase Personal Well-Being (Suicidal Indicators)

0

5

10

15

20

25

30

35

40

45

50



90-Day Retention in Long-Term Residential Community Programs

by Treatment Readiness and Legal Pressure

27

38

51

34

4654

0

20

40

60

80

100

No Legal Pressure Legal Pressure

Low Readiness Moderate Readiness High Readiness

N=2194; Knight, Hiller, Broome, & Simpson, 2000 (JOR)

Probationer Response to Treatment(% with Problems in Psychological Functioning)

0

5

10

15

20

25

30

35

Intake Mid-Treatment At Discharge

AnxietySelf-esteemDepression

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

HighHigh(modified TC)(modified TC)

HighHigh(modified TC)(modified TC)

Key Issues

AftercareAftercare AftercareAftercare

SelectionSelection of of

TreatmenTreatment? t?

SelectionSelection of of

TreatmenTreatment? t?

ProblemProblemSeverity?Severity? ModerateModerate

(12-steps)(12-steps)ModerateModerate(12-steps)(12-steps)

LowLow(education)(education)

LowLow(education)(education)

Intensity Levels ?

2 of every 3Inmates haveUsed drugs

• EngagementEngagement• PerformancePerformance• OutcomesOutcomes

Historical Overview of Prison-Based Treatment Evaluations

27

41

29

74

26

63

28

64

0

20

40

60

80

% Arrested (2+ Years) Stay'n Out

% Imprisoned(3 Years)

Cornerstone

% Jailed (1 Year)

Amity

% Arrested (18 Months)

Key-Crest

Treatment

No treatment

In: Orientation to Therapeutic Community, 1998, Mid-America ATTC

Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates

71

95

72

83

45

73

31

65

No Treatment

(n=210)

ITC Dropout*(n=109)

ITC, but noAftercare*

(n=101)

ITC +Aftercare*

(n=69)

% with New Arrests% with Drug Use

Martin, Butzin, Saum, & Inciardi, 1999 (The Prison Journal)

*p<.05(adjusted

diff vs.No Trt)

California/Amity Program: 3-Year Return-to-Custody Rates (%)

7582 79

27

No Treatment

(n=189)

ITC Dropout(n=73)

ITC, but noAftercare(n=154)

ITC +Aftercare*

(n=162)

Wexler, Melnick, Lowe, & Peters, 1999 (The Prison Journal)

*p<.001

10

30

12

18

32

16

111

14

No Treatment

(n=58)

AftercareDropouts(n=101)

AftercareCompleters*

(n=123)

Year 3Year 2Year 1

Knight, Simpson, & Hiller, 1999 (The Prison Journal)

Texas/High-Severity Group: 3-Year Return-to-Custody Rates (%)

26

52

66

*p<.01

Texas/New Offenses Only: 3-Year Return-to-Custody Rates (%)

1922

6

NoTreatment

AftercareDropouts

AftercareCompleters

Knight, Simpson, & Hiller, 1999 (The Prison Journal)

SufficientSufficientRetentionRetentionSufficientSufficientRetentionRetention

Early Early EngagementEngagement

Early Early RecoveryRecovery

PosttreatmentPosttreatment

DrugDrugUseUse

DrugDrugUseUse

CrimeCrimeCrimeCrime

SocialSocialRelationsRelations

SocialSocialRelationsRelations

ProgramProgramParticipationParticipation

TherapeuticTherapeuticRelationshipRelationship

BehavioralBehavioralChangeChange

Psycho-SocialPsycho-SocialChangeChange

InmateInmateAttributesAttributes

InmateInmateAttributesAttributes

MotivMotiv

Evidence-Based Treatment Model

SupportiveSupportiveNetworksNetworks

SupportiveSupportiveNetworksNetworks

InductionInductionneeded?needed?

Simpson, 2001 (Addiction)

AftercareAftercare

Problems at Treatment Admission(TCU Self-Ratings at Intake in 1996)

26

30

42

39

57

27

20

Self-esteem

Depression

Anxiety

Childhood

Risk-taking

Hostility

Trt Readiness % of Probationers

N=409; Dees, Pitre, & Dansereau, 1997, Annual Report on 1996 Intakes

ChangesChangesover over time?time?

Hostility and Treatment Dropout Rates(% with high Hostility scores [4+ on 1-7 scale])

29

5052

242625

21

10

20

30

40

50

60

Intake Month 1 Month 3 Month 6

Dropouts (N=97/58)

Completers (n=290)

N=399; Broome et al., 2000, ACJS Conf Presentation (New Orleans)

-

-

+

+

Predictors of Early Engagement

PersonalPersonalInvolvementInvolvement

PsychosocialFunctioning at

Intake

Client Ratings at Month 1

N=399 ; Hiller et al., in progress, 1998 Wilmer admissions

BackgroundCharacteristics

PersonalPersonalProgressProgress

Trust inTrust inStaffStaff

AgeAgeAgeAge

FemaleFemaleFemaleFemale

Alcohol ProbAlcohol ProbAlcohol ProbAlcohol Prob

Coc ProbCoc ProbCoc ProbCoc Prob

+

SelfSelfEfficacyEfficacy

SelfSelfEfficacyEfficacy

AnxietyAnxietyAnxietyAnxiety

HostilityHostilityHostilityHostility

DesireDesirefor Helpfor HelpDesireDesire

for Helpfor Help

Multivariate Model of Early Dropout

(Stepwise Logistic Regression)

BackgroundBackgroundBackgroundBackground

Early Early DropoutDropout

Early Early DropoutDropout

PsychosocialPsychosocialPsychosocialPsychosocial

Odds Ratio=2.6

Odds Ratio=1.5

Odds Ratio=2.1

N=339; Hiller, Knight, & Simpson, 1999 (The Prison Journal)

High RiskHigh RiskHigh RiskHigh Risk

Low Self-efficacyLow Self-efficacyLow Self-efficacyLow Self-efficacy

UnemployedUnemployedUnemployedUnemployed

Multi-Site Predictors of Recidivism

RecidivismRecidivism

Hiller et al., 1999 (Addiction); Wexler et al., 1999 (CJB)

Younger AgeYounger Age

Previous ArrestsPrevious Arrests

ASP/HostilityASP/Hostility

Childhood ProblemsChildhood Problems

MotivationalMotivationalReadinessReadiness

MotivationalMotivationalReadinessReadiness

Trt SatisfactionTrt SatisfactionTrt SatisfactionTrt Satisfaction

AftercareAftercareCompletionCompletion

-

StrongestPredictors

Male New Admissions to Prison by Type of Offense with Tx Bed Growth

0

2000

4000

6000

8000

10000

12000

14000

16000

1997 1998 1999 2000 2001 2002

YEAR

Total # ofTx Beds

Drugs

Property

Person

Other

R.Krupp – CDC-OSAP, in press. 3/03

Female New Admissions to Prison by Type of Offense w ith Tx Bed Growth

0

500

1000

1500

2000

2500

3000

1997 1998 1999 2000 2001Year

Total # of TxBeds

Drugs

Property

Person

Other

Property

* Person

Other

R.Krupp – CDC-OSAP, in press. 3/03

Does In-Custody Therapeutic Community Have Any Impact

On Custody Staff?

Let’s find outLet’s find out

Inmate Rules Violation Reports(115’s)

408

67

265

101

322

79

166

61

Violence/Threat ofViolence

Non-violent DisruptiveBehavior

Failure to Program Grooming Standards

General Population Treatment

In: Corrections Compendium, 2001, Deitch, Koutsenok et al.

Inmate Rules Violation Reports(115’s)

1273

511

Serious 115's


In: Corrections Compendium, 2001, Deitch, Koutsenok et al

Use/Possession ofControlled 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)


Sick Related Absenteeism(Sick Calls)

1234

522

General Population TreatmentIn: Corrections Compendium, 2001, Deitch, Koutsenok et al

Occupational Injuries(Documented Worker’s Comp)

1070

358

28

Related to Assaults Not Related to Assaults



Effects of Treatment Environment on Custody Staff: Perception of Health

0

5

10

15

20

25

30

35

Excellent Very Good Fair Poor

General Pop. Treatment


Custody Staff - Perceptions of Job-related Stress (SATF-SAP)


0

1

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10

General Pop. TreatmentNo Stress High Stress

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.

in custody treatment rationale, outcomes and directions david a. deitch, phd professor of clinical...

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