# Presentation: 757500

## Corrections-Based Treatment for Drug-Involved Offenders

**James A. Inciardi, Ph.D.**
**Center for Drug and Alcohol Studies**
**University of Delaware**
**160****th**** Annual Meeting of the American Psychiatric Association**
**San Diego, California, May 19-24, 2007**

## Background

**As of June 30, 2006, more than 2.3 million persons were being held in U.S. jails and prisons.**
**Estimates suggest that more than 70% of these prisoners have significant histories of drug and alcohol abuse.**

## Participation in Drug/Alcohol Abuse Treatment During Incarceration

- Urban Institute, 2003

**None 80%**

**Drug / Alcohol Treatment**
**2%**

**AA or NA Participation**
**8%**

**Both**
**10%**

## Why Treat Drug-Involved Offenders During Incarceration?

**Time is what most inmates have plenty of.**
**It is a good time to talk about risks for HIV & AIDS, and staying safe.**
**There is the need to encourage pro-social concepts, as opposed to those fostered by the “inmate culture.”**

## What is the “Inmate Culture”?

**The inmate culture is composed of the ways of acting, thinking, and feeling about all aspects of prison life that help inmates cope with the special circumstances of incarceration. **
**The inmate culture glorifies anti-social thoughts, feelings, and behaviors, and many inmates repeatedly engage in anti-social behaviors while incarcerated.**
**As part of the inmate culture, respect is typically reserved for the most cunning and most violent offenders.**

## Impact of the Inmate Culture

**The inmate culture often puts offenders in a mental relapse mode before they are even released.**
**In other words – inmates are programmed for failure upon release to the community.**
**What do inmates say they will do as soon as they “hit the streets”?**
**Make some money (legally or otherwise).**
**“****Sex it up!”**
**Get high.**
**Anything else is considered “punk stuff.”**

## What Kind of Treatment is Best During Incarceration?

**Treatment should be in a residential setting.**
**Isolated from the drugs, violence, and prison subcultures that tend to militate against positive behavioral change.**
**Research suggests that for criminal offenders with long histories of substance abuse, the “*****therapeutic community*****” is likely the most viable treatment approach.**

## The Treatment Perspective of the Therapeutic Community (TC)

- Drug abuse is a disorder of the whole person;
- The problem is the _person_ and not the drug;
- Addiction is a _symptom_ and not the essence of the disorder; and,
- The primary goal is to change the negative patterns of behavior, thinking, and feeling that predispose drug use.

## An Effective Approach for Corrections-Based Treatment

- 	The literature in the fields of treatment and corrections, as well as clinical and research experiences with correctional systems and populations, suggest that  the _most effective treatment strategy_ for incarcerated, drug-involved offenders should have _three stages of intervention:_

## Stages of Treatment

**Each stage of this treatment continuum should be adapted to the individual’s changing correctional status:**
**Incarceration**
**Work Release**
**Parole (or other community form of supervision)**

## Stages of Therapeutic Community Treatment for Drug-Involved Offenders

**Prison-Based TC**
**Work Release TC**
**Aftercare**

## Prison-Based TC

**Segregated from the general prison population**
**12-15 months prior to work release or transitional custody eligibility**
**Same therapeutic mechanisms seen in community-based therapeutic communities**
**Interaction with “recovering addict” role models**
**12-15 months duration**

## Work Release TC

**Segregated from general work release population **
**Clinical regimen modified to address the correctional mandate of work release**
**5-7 months duration**

## Aftercare 

**Outpatient counseling and group therapy on a weekly basis**
**Booster sessions with counselors**
**Family groups monthly**
**1 day per month in facility**

##  Delaware’s “Key” Therapeutic Community

**All Men**
**Established in 1988 (BJA funding)**
**From 20 to over 300 beds at two locations**
**State funded since 1991**

## Delaware’s “Key Village”Therapeutic Community

**All Women**
**Established in 1994 (CSAT funding)**
**90 beds**
**Funded by state since 1997**

## Delaware’s CRESTOutreach Center

**Women and men**
**Established in 1991 (NIDA funding)**
**65 beds at 1 location; expanded to 330 beds at 3 locations**
**Funded by state since 1995**
**Incorporates transitional and aftercare treatment**

## Research Groups in Delaware TC Follow-up Studies

**Comparison Group**
**Treatment Drop-outs**
**Treatment Graduates**
**Treatment Graduates with Aftercare**

## Data Collection

**Within 30 days prior to release from the “KEY” and “KEY Village” TC programs**
**  ****6-month Follow-up**
**18-month Follow-up**
**42-month Follow-up**
**60-month Follow-up**

**Frequency of baseline and follow-up data collection and research-based urine testing:**

## % Arrest-Free Since Release at 18-Month Follow-up

***Significantly different from comparison group at p<.05. **Estimates are derived from logistic regression
-   coefficients controlling for demographics, criminal and drug use histories, and time in treatment program.

_**Comparison: **_
**N=242**
_**Drop-outs:**_
** ****N=184**
_**Completed Treatment:**_
**  ****N=172**
_**Completed Treatment & Aftercare:**_
**N=207**

- *

- *

- *

## % Drug-Free Since Release by Self-Report and Urine Test at 18-Month Follow-up

*** Significantly different from comparison group at p<.05. **Estimates are derived from logistic  regression coefficients controlling for demographics, criminal and drug use histories, and time in treatment program.

_**Comparison: **_
**N=242**
_**Drop-outs:**_
** ****N=184**
_**Completed Treatment:**_
**  ****N=172**
_**Completed Treatment & Aftercare:**_
**N=207**

- *

- *

- *

## % Arrest-Free Since Releaseat 5-Year Follow-up

**Significantly different from comparison group at p<.05. **Estimates are derived from logistic regression
-   coefficients controlling for demographics, criminal and drug use histories, and time in treatment program.

_**Comparison: **_
**N=217**
_**Drop-outs:**_
** ****N=108**
_**Completed Treatment:**_
**  ****N=91**
_**Completed Treatment & Aftercare:**_
**N=124**

- *

- *

- *

## % Drug-Free Since Release by Self-Report and Urine Test at 5-Year Follow-up

*** Significantly different from comparison group at p<.05. **Estimates are derived from logistic regression
-   coefficients controlling for demographics, criminal and drug use histories, and time in treatment program.

_**Comparison: **_
**N=217**
_**Drop-outs:**_
** ****N=108**
_**Completed Treatment:**_
**  ****N=91**
_**Completed Treatment & Aftercare:**_
**N=124**

- *

- *

## Percentages with No New Drug Use Through 5 Years, and Percentages of Those Who Relapsed Earlier but Had No New Drug Use in 5th Year

- Estimates are derived from logistic regression coefficients controlling for demographics, criminal and drug use histories, and time in treatment program.

## Some Important Considerations

**	****T****hese analyses demonstrate that:**
**“****length of stay” is a key variable in  treatment outcome**
**aftercare during re-entry plays a crucial role in a comprehensive treatment regimen.**

## The Autonomy Issue

- 		**Although corrections-based treatment initiatives must be sensitive to the custodial demands of the prison administration, programs must have major input in terms of admission and release criteria, and the day-to-day operations of the program.  **
**	****	****Otherwise, the inclusion of inappropriate clients in the treatment continuum undermines overall program effectiveness.**

## Technology Transfer in the U.S.

**The Delaware model was the recommended protocol for the U.S. Deptepartment of Justice’s Residential Substance Abuse Treatment (RSAT) initiative for state prisoners.**
**300 programs throughout the United States and its territories were established under the RSAT initiative.**
**RSAT participation results in lower rates of relapse and recidivism for the majority of clients.**** **

## International Technology Transfer

- The Delaware TC continuum of treatment has been replicated in:

- Argentina
- Austria
- Australia
- Belgium
- Bulgaria

- Panama
- Romania
- Spain
- Thailand

## 	This research was supported by HHS Grant # R37 DA 06124 from the National Institute on Drug Abuse