National Institute on Drug Abuse

RESEARCH

MONOGRAPH SERIES

Drug Abuse

Treatment in

Prisons and Jails

U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health

118
Drug Abuse Treatment

in Prisons and Jails

Editors:

Carl G. Leukefeld, D.S.W.

Frank M. Tims, Ph.D.

NIDA Research Monograph 118

1992

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20857

For sale by te U.S. Government Printing Office

Superintendent of Documents, Mail Stop: SSOP. Washington, DC 20402-9328

ISBN 0-16-036155-9
ACKNOWLEDGMENT

This monograph is based on the papers from a technical review on “Drug Abuse

Treatment in Prisons and Jails” held on May 24-25, 1990, in Rockville, MD. The

review meeting was sponsored by the National Institute on Drug Abuse.

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may be used or reproduced without permission from the Institute or the authors.

Citation of the source IS appreciated.

Opinions expressed in this volume are those of the authors and do not

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Abuse or any other part of the U.S. Department of Health and Human Services.

The U.S. Government does not endorse or favor any specific commercial

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publication are used only because they are considered essential in the context

of the studies reported herein.

NIDA Research Monographs are indexed in the Index Medicus. They are

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Information Service, Chemical Abstracts, Current Contents, Psychological

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DHHS publication number (ADM)92-1884

Printed 1992

i i
Contents

Page

The Challenge of Drug Abuse Treatment in Prisons

and Jails

Frank M. Tims and Carl G. Leukefeld 1

Correctional Drug Abuse Treatment in the

United States: An Overview

Douglas S. Lipton, Gregory P. Falkin, and

Harry K. Wexler 8

Program Models

Drug Treatment Services in Jails

Roger H. Peters and Robert May II 38

HIV-1 Infection in the Correctional Setting

David Vlahov 51

Drug Abuse Treatment Programs in the Federal Bureau of

Prisons: Initiatives for the 1990s

Donald W. Murray, Jr 62

Amity Righturn: A Demonstration Drug Abuse Treatment

Program for Inmates and Parolees

David L. Wineit, Rod Mullen, Lois L. Lowe,

and Elizabeth A. Missakian 84

Substance Abuse Services in Juvenile Justice:

The Washington Experience

David Brenna 99

Barry S. Brown 31

iii
Florida Department of Corrections Substance

Abuse Programs

Wilson C. Bell, James G. Mitchell, Jennifer Bevino,

Abbas Darabi, and Richard Nimer 1 10

Comprehensive System Development in Corrections

for Drug-Abusing Offenders: The Wisconsin

Department of Corrections

Gerald L. Vigdal and Donald W. Stadler 126

Oregon Prison Drug Treatment Programs

Gary Field 142

Outcome Evaluation of a Prison Therapeutic Community

for Substance Abuse Treatment

Harry K. Wexler, Gregory P. Falkin, Douglas S. Lipton,

and Andrew B. Rosenblum 156

Obstacles to the Implementation and Evaluation of Drug

Treatment Programs in Correctional Settings:

Reviewing the Delaware KEY Experience

James A. Inciardi, Steven S. Martin, Dorothy Lockwood,

Robert M. Hooper, and Bruce M. Wald 176

Evaluation of In-Jail Methadone Maintenance:

Preliminary Results

Stephen Magura, Andrew Rosenblum,

and Herman Joseph 192

Management of the Drug-Abusing Offender

John Gregrich 211

A Coordinated Approach for Drug-Abusing Offenders:

TASC and Parole

Beth Weinman 232

Methodological Issues: Drug Abuse Treatment in Prisons and Jails

Bennett W. Fletcher and Frank M. Tims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Evaluation of the Federal Bureau of Prisons’

Drug Treatment Programs

Bernadette Pelissier and Dan McCarthy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261

iv
Directions for Practice and Research

Carl G. Leukefeld and Frank M. Tims 279

List of NIDA Research Monographs 294

v

The Challenge of Drug Abuse

Treatment in Prisons and Jails

Frank M. Tims and Carl G. Leukefeld

INTRODUCTION

Drug dependence and abuse among incarcerated populations is a stark

reality that enormously complicates the task of rehabilitating offenders.

Estimates of serious drug involvement among offenders points to the

urgent need for effective interventions, and available indicators show drug

use among arrestees to be at epidemic levels (Lipton et al., this volume).

During the 1970s it was pointed out that only about half the Nation’s State

prisons offered drug abuse treatment (Tims 1981), and only about one-quarter

of all jails in the United States had any provision for treatment (Newman and

Price 1976). In fact, a review of the National Drug and Alcohol Treatment

Utilization Survey from 1976 through 1979 showed a decline in the number of

available treatment slots in correctional institutions (Tims 1985). During the

1980s the prison population increased dramatically to more than half a million,

and the overall prevalence of drug involvement among incarcerated offenders

also rose markedly.

There are numerous reasons for offering drug abuse treatment to these

populations. First, there is the matter of institutional management. Newman

and Price (1976) pointed out that sheriffs reported fewer administrative

problems with inmates who received some treatment, usually detoxification,

while in jail. Second, there was reduction in drug-seeking behavior by the

incarcerated population, and third, jails and prisons offer an opportunity to

engage the drug-dependent individual in a rehabilitation process. Thus, for

many drug abusers, incarceration may be the only contact with treatment

providers.

The nature of drug dependence is a chronic, relapsing condition, and recovery

is a continuing process. Although engagement in treatment may begin in a

prison or jail setting, aftercare—or continuing care—is critically important.

Thus, a model of treatment should include prerelease treatment, transitional

care, and aftercare or continuing treatment.

1
NOTHING WORKS

A common criticism of offender rehabilitation programs is that “nothing works”;

that is, nothing has been shown to evoke such dramatic improvements as to

satisfy the program critics. In fact, almost any student of programs that have

been tried in correctional settings can point to some concrete achievement.

Indeed, the case for treating those who are serving finite incarceration terms

and who have some motivation to live drug-free, productive lives seems to

be effective from the practitioner’s point of view. But evidence of program

effectiveness is also noted from scientific studies. Amassing such evidence

must be viewed in the context of the usual high relapse rates that are certain

to be cited as indications that these interventions are not successful. It could

even be argued that, given the complexity of the problems as well as the

economic and social costs inherent in continued drug abuse after release from

jail or prison, gains of the magnitude observed thus far more than justify the

resources devoted to those programs. However, the evidence for treatment

in general and treatment under legal pressure in particular is even more

encouraging. For example, it has been shown that those entering communitybased drug abuse programs under legal sanction do as well as those who

enter voluntarily (Hubbard et al. 1989). Whether drug abuse treatment

programs directed at incarcerated populations produce lasting change is one

question that has been debated but never satisfactorily answered, although

there are multiple examples of correctional programs attracting incarcerated

clients into drug abuse treatment (Lipton et al., this volume; Wexler et al., this

volume; Magura et al., this volume).

THE CHALLENGE OF DEVELOPING RESPONSIVE TREATMENT

PROGRAMS

Developing viable and evaluable programs is a major challenge to those

charged with the responsibility for treating drug abusers. As Lipton and

colleagues (this volume), Magura and colleagues (this volume), and Fletcher

and Tims (this volume) point out, this is no simple task. The program must

have continuing organizational support, a conceptual basis, and clear

objectives, all of which should feed into an evaluation design. The evaluation,

in turn, can be the basis for program improvement. Several laudable attempts

at such designs and evaluations of prerelease and aftercare programs were

initiated in the 1970s. The most notable was at the Federal level, “Project

TRAP” (Treatment and Rehabilitation of Addicted Parolees), with a prerelease

component, a transitional component, and a community corrections (aftercare)

component. Grants were given by the Law Enforcement Assistance

Administration, U.S. Department of Justice, to four States for controlled studies

of TRAP models. Program service integration and evaluation were required,

2
and evaluation was to be conducted by an independent organization. However,

the program did not have a fair trial because Federal budget cuts produced

premature grant terminations.

Another example is a Wisconsin prerelease demonstration program structured

as a therapeutic community. This demonstration incorporated a transitional

reentry program at a different site, community aftercare, and an integrated

program design and evaluation design for the entire program and the individual

elements. Unfortunately, the rate at which prisoners were paroled was

insufficient to provide the necessary sample size for the evaluation design.

The design requirements, which involved random assignment of persons

with parole potential from a pool of volunteers having histories of drug

dependence, exceeded the number of available subjects, although there had

been no reason to expect that the numbers needed would not be available.

Still another effort involved a State that had a well-thought-out and executed

program of prerelease treatment and aftercare. However, the evaluation

contractor could not achieve a satisfactory completion rate for followup

interviews. Thus, all program elements were in place, but evaluation data

were lacking because a problem of contractor performance was not detected

in time for remedial action.

These three examples reveal several problems that confront advocates for

these treatment programs. Clearly, the program must be given a chance to

succeed or fail, which assumes an adequate and sustained funding level as

well as adequate institutional support over time. Evaluation designs also

must be supported by realistic projections of available subjects. In addition,

a program must have a continuing commitment to the integrity of better

programing and evaluation design as well as the practical requirements of

constantly monitoring the evaluation to resolve problems in a timely fashion.

The other critical ingredient is time. Programs should be given a fair chance

to mature. Evaluative research is necessarily a long-term endeavor. The

politicians, administrators, and treatment professionals who must advocate

support for these programs are frustrated by the delay in availability of “hard

data.” Lack of stable research funding in the past, together with compromises

in method and program budgets occasioned by events beyond the control of

treatment providers and administrators, has left the field even further behind

than reason suggests it should be in developing arguments for adequate

treatment.

3
NEW BEGINNINGS

Researchers and policymakers are at a point in the history of drug abuse

treatment in the United States where a frank assessment is needed of the

present state of knowledge and the most promising directions in treatment

programing indicated by the weight of clinical experience. Such new beginnings

call for a new realism, which is the driving force behind this monograph. A

body of knowledge was developed concerning treatment effectiveness (Tims

and Ludford 1984; Tims et al. 1991; Hubbard et al. 1989; Simpson and Sells

1990) and its effectiveness with criminal justice populations (Hubbard et al.

1989; Leukefeld and Tims 1990). In addition, studies have documented the

effectiveness of specific corrections-based programs (Wexler et al., this

volume; Anglin and McGlothlin 1984), and ongoing studies are adding to

that evidence (e.g., lnciardi et al., this volume; Magura et al., this volume).

Also, the National Institute on Drug Abuse (NIDA) has entered into a

memorandum of understanding with the U.S. Bureau of Prisons (BOP)

to provide evaluative support for its study of drug abuse treatment outcomes

in BOP inmate populations. NIDA’s involvement not only will strengthen the

BOP evaluation but also will increase comparability of these and other studies

by promoting the use of common instruments and methodologies. NIDA also

has entered into a similar relationship with the Bureau of Justice Assistance,

U.S. Department of Justice, to support research on corrections-based programs

and on case management strategies.

This new beginning must be accompanied by an assertion that the treatment

of drug abuse and dependence in incarcerated populations is a necessity

during incarceration. To consider it an “extra” aspect of jail or prison operation

ensures that it will be among the first items cut in the inevitable, cyclic periods

of budget austerity. Therefore, it will not be possible to guarantee that the

stable levels of support necessary for examining effectiveness will be provided.

Considering drug abuse treatment as separate from jail or prison operations

also carries the risk that it will not have the programmatic integration so

necessary for meaningful rehabilitation of drug-dependent offenders. Failure

to provide adequate treatment for this admittedly difficult problem means

that society will pay the price in the costs of recidivism, and the already

overburdened facilities will be subjected to further pressures.

Drug abuse treatment must be approached in a systematic and stable way.

Effective programs must be developed and refined, with emphasis on

assessment of needs, appropriateness of treatment, integrity of treatment,

continuity of care, and adequate aftercare programing. Aftercare cannot be

only a good intention and a paper plan but must include an active commitment

on the part of both the client and the parole system. In addition, aftercare

4
programing must be a proactive part of parole and consist of more than referral

or urine testing.

The range of available models also must be expanded to include linkages

with existing drug abuse treatment resources outside the jail or prison. These

models, which are linked to community treatment programs, provide a basis

for ensuring that continuity of care is conceptual as well as temporal. The

Key Extended Entry Program (KEEP), for example, provides methadone

maintenance to jail inmates who will be back on the streets in a relatively

short time. Many judges are reluctant to refer opiate addicts to methadone

programs, even though this is the treatment of choice for many. Therefore,

KEEP is an innovation. The value of such an innovation is that it engages the

addict during a vulnerable stage in his or her addiction career and provides a

link with a community-based program so that meaningful treatment can

continue after release from confinement (Magura et al., this volume).

Evaluation is essential, and resources must be made available. This is a

policy need (accountability) and a programmatic need (treatment improvement).

It also is needed because treatment improvement calls for better understanding

of the elements that contribute to treatment outcome. Thus, in the face of realworld constraints and limitations, the development of drug abuse treatment

programs must include evaluation designs that allow for methodologically

adequate assessment of effectiveness and analysis of process (Fletcher and

Tims, this volume).

CONCLUSION

This volume has several objectives. Given the limited, though somewhat

persuasive, data available on corrections-based treatments, it is particularly

important to bring together available research knowledge, program concepts,

and clinical insights regarding drug abuse treatment of incarcerated, drugdependent offenders. To meet these objectives, this review includes

activities that are in their early stages as well as requirements for effective

implementation of treatment and research strategies. In addition, it examines

programing in differing jurisdictions and across bureaucratic lines. In other

words, this is another step along the way to approach the complex and difficult

task of treating drug dependence in a framework that emphasizes a systematic

approach to treatment, continuity of care, stability of outcomes, research

support, and a continuing commitment to improving treatment.

5
REFERENCES

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict treatment in

California. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment

Evaluation: Strategies, Progress, and Prospects. National Institute on Drug

Abuse Research Monograph 51. DHHS Pub. No. (ADM)86-1329.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 106-128.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh, E.R.;

and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press, 1989.

Leukefeld, C.G., and Tims, F.M. Compulsory treatment for drug abuse. Int J

Addict 25(6):621-640, 1990.

Newman, C.M., and Price, B.R. Drug Treatmenf in Jails. State College, PA:

Pennsylvania State University, 1976.

Simpson, D.D., and Sells, S.B. Opioid Addiction and Treatment: A 12-Year

Follow-Up. Malabar, FL: Robert A. Krieger Publishing Co., 1990.

Tims, F.M. Drug Abuse Treatment in Prisons. Treatment Research Reports.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1981.

Tims, F.M. “Drug Abuse Treatment in Correctional Settings.” Paper presented

at the annual meeting of the Alcohol and Drug Problems Association,

Washington, DC, 1985.

Tims, F.M.; Fletcher, B.W.; and Hubbard, R.L. Treatment outcomes for drug

abuse clients. In: Pickens, R.W.; Leukefeld, C.G.; and Schuster, C.R., eds.

Improving Drug Abuse Treatment. National Institute on Drug Abuse

Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington,

DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 93-113.

Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment Evaluation:

Strategies, Progress, and Prospects. National Institute on Drug Abuse

Research Monograph 51. DHHS Pub. No. (ADM)86-1329. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1984.

AUTHORS

Frank M. Tims, Ph.D.

Deputy Branch Chief

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10A-30

5600 Fishers Lane

Rockville, MD 20857

6
Carl G. Leukefeld, D.S.W.

Director

Center on Drug and Alcohol Research

University of Kentucky

210 Medical Annex 2

Lexington, KY 40536-0080

7
Correctional Drug Abuse Treatment in

the United States: An Overview

Douglas S. Lipton, Gregory P. Falkin, and Harry K. Wexler

INTRODUCTION

There is no question in the mind of any responsible citizen that drug abuse is a

serious problem in the United States. There are many obvious measures that

might be taken. The urban news media daily carry stories and editorials related

to drug abuse, its casualties, and its consequences for public safety and the

quality of life. The Federal Government is making tax dollars available at an

unprecedented level for drug abuse treatment and prevention programs and

research as well as demonstration efforts. Federal spending on drug control

activities overall tripled from $1.2 billion to $3.9 billion from 1981 to 1988.

Although there is some controversy over the exact size of the drug abuse

problem and whether some drugs are declining in usage among householders

and high school students, there is no denying the magnitude of drug use among

persons arrested for felonies and misdemeanors. The Drug Use Forecasting

(DUF) system of the National Institute of Justice clearly documents the extent

to which persons involved in criminal lifestyles are engaged in the use of drugs

around the time of their arrests. All 22 cities now participating in DUF are

showing significant levels of cocaine and other drug use among their arrestees

regardless of charge, although there has been no evidence of an increase in

heroin use by male arrestees in the past few years. In every DUF city, opiates

have been found in less than 20 percent of tested males (except New York,

where the heroin-positive rate has ranged between 17 and 29 percent). In

contrast, cocaine levels consistently have been high in most cities. The highest

rates of cocaine use-above 60 percent-have been found in Washington, DC,

New York, and Philadelphia (Wish and O’Neil 1989). In figure 1, the proportion

of arrestees with positive urinalysis assays for cocaine is marked by a dark line

on the columns.

At the other end of the criminal justice funnel (i.e., at the incarceration level)

it is a safe assumption that the proportion of drug-using offenders among

those incarcerated is higher than their proportion among arrestees. In many

8
FIGURE 1. Percent of male arrestees who tested positive for any drug. The

proportion of arrestees who tested positive for cocaine is marked

by a dark line on the columns. Testing October to December

1988 for opium, cocaine, phencyclidine hydrochloride (PCP),

marijuana, amphetamines, diazepam (Valium), propoxyphene

hydrochloride (Darvon), methaqualone, barbituates, and

methadone.

SOURCE: National institute of Justice 1989

instances these men and women do not use a single drug but many different

drugs and mostly in combination with each other and with alcohol. If they are

chronic users, as the data of Johnson and coworkers (1986) would suggest,

their drug use pervades their lifestyle and preoccupies their daily hours. Most of

these persons have avoided treatment while active in the community, although

some have experienced detoxification several times. Their entry into the

country’s crowded jails and prisons stills their criminal predations for a while,

but the problems of prison crowding are of such enormity that for each person

incarcerated there is bound to be one released, and he or she is highly likely

to be an untreated drug user. At least 45 percent of arrestees charged with

violent crimes or income-generating crimes (like robbery, burglary, and theft)

tested positive for use of one or more drugs, according to “NIJ Reports”

(National Institute of Justice 1989). In the Federal prison system, cells for

31,000 (Office of National Drug Control Policy 1989) are holding more than

56,500 inmates (Murray, this volume). In the States, 533,000 are being held

9
in facilities for 436,000 (Abell 1989). All but eight States are under some kind

of court order or consent decree to relieve prison crowding. Much of this

prison crowding pressure is directly due to public outrage regarding drug-related

crime and the resultant tougher sentencing practices that have been enacted

for repeat offenders and criminals committing drug-related crimes, as well as

the dramatic increase in arrests directly related to crime increases generally.

Drug-using offenders are a substantial proportion of the pool of persons now

flooding the prisons and jails, and this trend of the 1980s appears likely to

continue undiminished into the current decade.

One legislative reaction to the public’s concern has been to accelerate prison

construction, but this is at the astronomical cost of $70,000 to $100,000 per

bed space. Operational costs added to construction costs and amortized over

the life of a facility still yields a per-inmate per-year cost averaging $25,000

(Abell 1989). Costs vary between $9,000 and $40,000 per year among the

States; the City of New York states its annual incarceration cost to be about

$57,000, according to the New York City Department of Correction Office of

Public Affairs. At the present time, about 14 percent of the criminal justice

system budget is being spent on such construction, double what it was in 1974

(Abell 1989).

With the advent of crack use in the mid-1980s the already heady relationship

between drugs and crime has quickened. Cocaine use has doubled in most

cities and tripled in some cities in the past 4 years, whereas other crime-related

drugs-notably heroin and PCP-have declined or remained stable (Wish and

O’Neil 1989). Crack-accelerated violence in the streets, particularly increasing

numbers of shootings of innocent bystanders, have angered the public;

consequently, there is increasing pressure on the police and the courts for

action. Cocaine users who were reasonably in control of their drug use say

they went out of control with crack; that is, they would do anything to continue

the crack high while on a binge. Pregnant crack-using women have abandoned

their newborns in hospital nurseries. Those who work with drug-using mothers

report that crack use is the most potent centrifugal force on the mother-child

relationship yet seen. Crack is apparently much more compelling than heroin,

with which drug treatment professionals are more familiar. Moreover, levels of

crack use have been reported to be increasing in rural, suburban, and urban

quarters of the country; consequently, rates of crack-related violent crime and

crack distribution crime and numbers of inmates in State prisons with crack

histories also have increased (Fagan et al. 1990).

Overall, the U.S. prison population has grown about 55 percent since 1981,

largely fueled by the major influx of drug-using offenders. These offenders—

among them the most predatory, the heroin-using “violent predators”—are

10
responsible for a relatively large amount of crime; compared with non-drugusing offenders, they committed 15 times as many robberies, 20 times as

many burglaries, and 10 times as many thefts (Chaiken 1986). Studies in

Baltimore (Ball 1986; Ball et al. 1981) and New York (Johnson et al. 1986) have

demonstrated that active drug use accelerates the users’ crime rate by a factor

of four to six and that crime content is at least as violent, or more so, than that

of non-drug-using counterparts. The subjects of these studies were heroin

users. Initial impressions from crack-crime studies indicate that crack-related

crime is as high as, or higher than, heroin-related crime and is certainly more

violent.

Although data vary across studies, it would appear that drug-using felons

are also a primary source of failure on parole. That is, they constitute a

disproportionate share of the repeat offenders. Of untreated parolees with

histories of heroin and/or cocaine use, 60 to 75 percent are reported to return

to heroin and/or cocaine use within 3 months after release and to become

reinvolved in criminal activity (Wexler et al. 1988a). The “revolving door”

analogy epitomizes the situation with hard-drug-using offenders, Since a

great proportion of American drug users are processed through some part

of the criminal justice system during their drug-using careers, it makes a great

deal of sense to consider that system as a location for treatment. Most inmates

have not been treated in the community, and when asked, they state that they

have no particular interest in entering treatment. Thus, the criminal justice

system is a major opportunity to bring to bear the state of the art in drug

abuse treatment for this otherwise elusive population.

PRISON TREATMENT PROGRAMS

In 1979, the National Institute on Drug Abuse (NIDA) conducted a

comprehensive survey of drug abuse treatment programs in prisons (Tims

1981). The survey identified 160 prison treatment programs serving about

10,000 inmates (4 percent of the prison population). In 1979, 49 programs

(32 percent of the programs) were based on the therapeutic community (TC)

model. They served about 4,200 participants (or 42 percent of all participants).

Chaiken (1989) and Chaiken and Johnson (1988) estimated that, in 1987,

11.1 percent of the inmates in the 50 States were in drug treatment programs.

Although this represents a sizeable increase (from 10,500 inmates in 1979 to

51,500 inmates in 1987), the vast majority of inmates with substance abuse

problems still do not receive treatment while in prison.

Although there is still no consensus about the percentage of offenders being

treated for drug use, recent incomplete surveys of treatment for incarcerated

drug abusers show that 39 States use preliminary assessment procedures with

11
newly sentenced inmates; 44 States allow Narcotics Anonymous (NA), Cocaine

Anonymous (CA), or Alcoholics Anonymous (AA) self-help group meetings once

or twice a week; 44 States have some form of short-term (35 to 50 hours) drug

education programing; 31 States have some form of individual counseling

available for drug users in which a counselor or therapist meets with an

individual inmate occasionally during the week; 36 States have group

counseling in which small groups of inmates meet once or twice weekly with

a therapist; and 30 States have some type of intensive residential program,

often based on the TC model. Most optimistically, less than 20 percent of

identified drug-using offenders are believed to be served by these programs

(Frohling 1989).

Unfortunately, little research evidence exists to support the effectiveness of

the sorts of correctional programing noted above with the exception of TCs.

Drug education and information programs are for basic support of other

programs. Their cost is low and can be maintained by inmates in resource

centers, but they do not constitute treatment. However, they are useful

adjuncts to self-help groups, group counseling, and various forms of milieu

therapy. Drug information and education is delivered on the premise that

persons using drugs or tempted to use them lack information about the drugs

or their consequences, Most drug-using inmates do not lack information

about the drugs or their consequences; in fact, most drug users are fairly

sophisticated street pharmacologists, and it is naive to think that improving the

depth and quality of information about drug abuse will deter future use. Drug

education programs do have utility and are probably cost-effective for naive

first-time offenders who were occasional drug users in the community, and they

are likely to be particularly useful when combined with more intense programing

for younger offenders with little drug experience.

Such self-help groups as NA, CA, and AA provide models for a drug-free

lifestyle and a support system to maintain the abstinence resolve upon release.

They are low-cost programs run by recovered persons who volunteer their

time to work with inmates. Using the AA 12-step model, they insist on sobriety,

encourage sharing experiences and problems related to drug dependence,

teach constructive tools to deal with the triggers to relapse, urge positive

alternatives to a drug-dependent lifestyle, and perhaps most importantly,

provide an important aftercare link-a network of supportive human resources

to help offenders returning to the community avoid relapse provoking pitfalls.

They also provide a focus for drug-free social interaction and leisure activity.

Although there is a good deal of anecdotal evidence, there is little research

evidence that has demonstrated long-term success of these programs with

drug users. Nevertheless, they are useful as part of an overall comprehensive

drug abuse continuity-of-care system, particularly when combined with more

intensive counseling or milieu efforts, and they are essentially cost-free.

12
Individual counseling is the least common program qua program but a

frequently available service that inmates can request within institutions.

Using one-to-one interviews with a psychologist, social worker, and in some

instances, psychiatrist, individual counseling sessions focus typically on

problems, feelings, attitudes, and behaviors. The ultimate goal of the sessions

is to improve the inmate’s self-image, sense of personal responsibility, and

ability to function in a socially acceptable manner. Styles may include

traditional psychotherapy, transactional analysis, behavior modification, and

reality therapy, depending on the training and inclination of the therapist and

the needs of the inmate patient. The likelihood of the effective use of this

modality is limited by the paucity of trained individual therapists working in

prisons and by its higher cost. Most research studies of the effectiveness

of individual counseling have shown little evidence of success in reducing

recidivism (and other negative behaviors), although positive psychological

changes have been demonstrated.

Group counseling is the most common intensive therapeutic method used

in prisons. It usually has 8 to 10 members meeting 1 to 2 days per week

with a trained professional. Although high expectations of involvement and

participation exist, and the focus is often on intensely felt personal problems,

the interaction is tempered by the presence of custody officers or the possibility

of revealing too much weakness or vulnerability in a group setting in which

the participants are members of and return to the general population after

each session. Much of the subject matter of the counseling sessions is offered

voluntarily by participating inmates, and the environment needs to be supportive

and psychologically safe for useful work to go on. Unfortunately, the group

counseling modality in most institutions is particularly beset by the pervasive

antisocial pro-criminal inmate subculture that exists in every prison. Despite

this powerful shortcoming, changes have been reported in the research

literature from time to time, particularly when the group is sustained with the

same competent and dedicated (and often charismatic) professional leader

for more than a year. And there are powerful additional components, such

as life skills rehearsal, role reversal, stress management, social skill practice,

problemsolving skills training, relapse prevention, and participation in AA-type

groups.

Milieu therapy programs are typically more intensive than the foregoing

programs. Milieu therapy for drug-abusing inmates is administered in an

isolated, drug-free living area within the prison and usually includes individual

and group counseling, mildly confrontational group sessions, peer interaction,

and other techniques noted above in connection with group counseling.

The staff usually comprises professionals, such as social workers and

psychologists, and specially trained corrections officers. Costs are higher for

13
the above-mentioned modalities, but success rates are significantly higher

than for group counseling alone. Milieu programs appear to be best suited for

chronic multidrug users with addiction histories of fewer than 5 years. Although

time in program is an important factor in achieving higher success levels,

research shows that longer times in treatment in milieu therapy do not produce

as profound an effect on recidivism as do longer terms in TCs (Falkin et al.

1990).

THERAPEUTIC COMMUNITY APPROACH

With respect to community-based TCs, more than 20 years of program-based

and multimodality studies have yielded an impressive knowledge base

concerning the modality. Simply stated, more than 40 percent of clients

formally treated in TCs maintain favorable outcomes to the most stringent

criteria (no illicit drug use and no crime), and an additional 30 percent improve

over their pretreatment status (De Leon 1989). Among program graduates

who were followed for 7 years after treatment, success rates exceed 75

percent. Among dropouts, success rates average 30 percent. All studies

of residential TCs demonstrate the positive relationship between favorable

outcome and length of stay in treatment (De Leon 1989).

Prior to 1980, relatively few outcome research studies of TCs in prison settings

had been conducted. In a study of inmates who participated in various kinds

of prison-based drug treatment programs, Nash (1973) found no significant

differences in arrest rates among inmates who had participated in four TCs,

one non-TC residential program, and two drug counseling programs when

compared with a nontreatment comparison group. In an extensive reanalysis

of Nash’s data, Des Jarlais and Wexler (1979) found that participants in two of

the four prison-based TCs did significantly better than the comparison group

in terms of reduced drug use and criminality following release. Recently,

published findings regarding the Stay’n Out program (Wexler et al. 1988b,

1990a) and the Cornerstone program (Field 1985, 1989) substantiate the

significant accomplishments of correction-based TCs with incarcerated

drug-abusing felons.

Stay’n Out

The Stay’n Out program, a TC for the treatment of incarcerated drug offenders,

has been identified as a national model. Stay’n Out began as a joint effort by

the New York State Division of Substance Abuse Services, which funded the

program during its first years; New York Therapeutic Communities (NYTC),

which operates it; and the New York State Department of Correctional Services,

which currently funds it. It has two sites: a program for male offenders at the

14
New York State Arthur Kill Correctional Facility on Staten Island established in

1977, and one for females, which opened in 1978, at the Bayview Correctional

Facility in Manhattan. Currently, there are three treatment units at the Arthur

Kill Correctional Facility, with about 35 beds per unit (a total capacity of 146

beds), and one female treatment unit at the Bayview Correctional Facility, with

40 beds.

In 1984 NIDA provided a grant to Narcotic and Drug Research, Inc. (NDRI)

to evaluate Stay’n Out and compare it with other prison drug abuse treatment

programs. The evaluation was designed to test the proposition that effective

treatment of substance abusers is possible within prison (Wexler et al. 1990a).

A large-scale, quantitative analysis was conducted relating several measures of

treatment outcome (e.g., rearrest, reincarceration) to both client characteristics

and program attributes (time in program and termination status). The study

included males and females as well as treatment and no-treatment comparison

groups. Statistical analyses were performed to test several hypotheses,

including the following: that the Stay’n Out TC is more effective at reducing

recidivism than no treatment and alternative prison-based drug treatment

modalities and that increases in time in program would be related to reductions

in recidivism. These two hypotheses were confirmed, with the main finding

being that, as time in TC treatment increases, recidivism declines significantly.

Since the program began, nearly 1,000 men and more than 500 women have

been admitted to treatment. The aim of the program is to treat felony offenders

for their drug abuse and related problems so that they are less likely to

recidivate after leaving prison. Inmates selected for the programs are recruited

at State correctional facilities. The criteria for admission to the program are

official history of drug abuse (or indication of involvement in the drug culture);

at least 18 years of age; evidence of positive institutional participation; no

history of extensive violence, arson, sex crimes, or mental illness; and that

inmates be no more than 12 months nor less than 6 months away from their

first parole hearing.

On average, males in the Stay’n Out program have been convicted previously

four times and have been incarcerated for 4 years (prior to admission into

Stay’n Out). Most of the offenders are in prison for robbery (43 percent), drug

sales (18 percent), or burglary (18 percent). Drug abusers in the Stay’n Out

program have been heavily involved with drug use since the mean age of

16 1/2. Seventy-three percent of the clients have abused opiates; 77 percent

have abused cocaine (and other stimulants). Previous attempts at changing

their lifestyle have ended with two prior treatment failures averaging 18 months

in treatment combined.

15
The Stay’n Out programs at Arthur Kill and Bayview are TCs modified to fit into

a correctional institution. (For a full description of the program, see Wexler and

Williams 1986.) During the early phase of treatment, the major clinical thrust

involves observation and assessment of client needs and problem areas.

Orientation to the prison TC procedures occurs through individual counseling,

encounter sessions, and seminars. At the outset, clients are given low-level

jobs and granted little status. During the latter phases of the recovery process,

residents are given opportunities to earn higher level positions and increased

status through sincere involvement in the program and hard work. Encounter

groups and counseling sessions are more indepth and focus on the areas of

self-discipline, self-worth, self-awareness, respect for authority, and acceptance

of guidance for problem areas. Seminars take on a more intellectual nature.

Debate is encouraged to enhance self-expression and to increase selfconfidence.

Stay’n Out clients are housed in units isolated from the general prison

population. They eat in a common dining room, however, and attend morning

activities with other prisoners. Most program staff members are ex-addicts who

are graduates of community-based TCs as well as ex-offenders. Employed by

NYTC, they act as role models demonstrating successful rehabilitation. NYTC

has an annual contract with the New York State Department of Correctional

Services to provide the entire Stay’n Out program at both facilities. All but one

of the units are staffed by a unit director and three counselors; one unit at

Arthur Kill has only two counselors.

Upon release, participants are encouraged to seek further substance abuse

treatment at cooperating community-based TCs. About half the program

graduates continue in residential programs. Extensive involvement with a

network of such community TCs is central to the program’s operation. Staff

and third-phase residents of community TCs visit Stay’n Out on a regular basis

to recruit resident inmates for their programs. These visitors provide inspiration

since they are ex-addicts and ex-felon role models who are leading productive

lives.

The evaluation research design compared a male TC treatment group (n=435)

and a female TC group (n=247) to no-treatment control groups and alternative

treatment groups. The male treatment group was compared to the no-treatment

control group (n=159), which consisted of inmates who were on a waiting list for

the program. They met all the criteria for admission except the parole time

eligibility criterion and, therefore, completed their prison term without treatment.

The male treatment group also was compared with a milieu treatment group

(n=576), which offered a less intensive treatment than the TC. That is, time

was less structured; there was no hierarchy of jobs or social roles; counselors

16
were not ex-addicts or ex-offenders but were trained correctional officers; good

conduct in the program was not rewarded with greater responsibility; and

interaction with community TCs was less extensive.) In addition, the male

treatment group was compared with a counseling group (n=261), which

only received individual and group counseling once a week. The female

treatment group was compared to a no-treatment control group (n=38)

and with a counseling treatment group (n=113); these groups were similar

to their male counterparts. (That is, the control group met the basic criteria

for admission but did not receive treatment, and the alternative treatment

group received only counseling services.)

In general, the background characteristics of the samples were comparable,

except that the male milieu group had a significantly higher mean age and

criminal history score (a weighted average of prior criminal arrests, convictions,

and sentences) and spent more time in prison than the other male groups.

Multivariate statistical analyses were performed to control for the possible

confounding effects of these differences on treatment outcomes. The groups

were compared according to several recidivism measures: the percentage

arrested, the mean number of months until arrest, the percentage positively

discharged from parole, and the percentage not reincarcerated. The sampling

timeframe was based on inmates released from prison between 1977 and

1984; the followup period (which ended in 1986), therefore, ranged up to 9

years, depending on the year prisoners were released. (Almost all had at

least 3 years, and many had 6 years, of followup.)

Statistical analyses were performed to compare the effectiveness of TC

treatment with alternative interventions and no treatment and to assess the

relationship between treatment outcomes and time in treatment. The acrossgroup comparisons yielded mixed results (i.e., when compared with the other

groups, the TC groups had significantly lower arrest rates, but differences in

other outcome variables were not significant); however, the most powerful

finding was that there was a consistent and significant correlation between

treatment outcomes and time in program. The Stay’n Out evaluation research,

like other TC evaluation research, consistently found statistically significant and

salient effects between time in program and treatment outcomes. Generally

speaking, failure to look at time in treatment is almost always bound to mask

important findings and to yield spurious, no-difference outcomes.

Male and female Stay’n Out clients do better on parole if they remain in

the program for 9 to 12 months rather than terminating earlier (or later).

Furthermore, time in the comparison modalities does not produce a positive

effect. This pattern was found to be consistent for the other outcome variables

as well, leading to the firm conclusion that Stay’n Out is more effective than no

17
treatment and alternative treatments, especially so when clients remain in

treatment for an optimal period.

Insofar as testing the hypothesis that treatment outcomes improve as time in

program increases, several statistical analyses were performed on subgroups

of TC clients that spent varying amounts of time in treatment. For example,

when clients who completed the program in 9 to 12 months were compared

with clients who left within 3 months, differences between the percentages

positively discharged from parole for the two treatment periods were significant.

Among the males who terminated in less than 3 months, the percent with

favorable outcomes was only 49.2 percent, whereas the counterpart rate for

the males who stayed in the program for 9 to 12 months was 77.3 percent.

Similar findings were obtained for the females, although the percentages with

favorable outcomes were generally higher than for their male counterparts

(79 percent for females in treatment less than 3 months, 92 percent for the

9- to 12-month group).

For those who failed (i.e., those rearrested or reincarcerated), more time in TC

treatment also was related to positive treatment outcomes. When the mean

time until arrest was compared for the two termination periods, it was found

that clients who received treatment for shorter periods were arrested much

sooner than those who stayed in the program for 9 to 12 months. Furthermore,

the percentage of Stay’n Out male clients who were not reincarcerated after 9

to 12 months of treatment was considerably higher (72 percent within 3 years

after release from prison) than for males who resigned or were dismissed earlier

(60 percent within 3 years). Indeed, a logistic regression analysis showed that

the odds of not being reincarcerated were nearly three times greater for clients

who remained in treatment for 9 to 12 months than for clients who spent less

than 9 months in treatment.

A related analysis compared clients who completed the program favorably (53

percent) with those who resigned and were dismissed (32 percent). (Neutral

terminations, such as transfers for institutional reasons or death, accounted for

15 percent of the terminations.) A significantly higher percentage of clients

who completed the program favorably were not reincarcerated (72 percent

within 3 years) as compared with clients who terminated negatively (61 percent

within 3 years). The positive influence of time in program on outcomes was

independent of the effects of background variables. Regression analyses

showed that time in program was positively related to time until arrest and

reincarceration when other significant background variables (age and criminal

history) were held constant. Furthermore, time spent in the Stay’n Out TC

reduced reincarceration, whereas time spent in the comparison modalities

did not.

18
Clients who received 9 to 12 months of treatment were not only less likely to

recidivate than clients who spent less time in treatment, but they also did better

than clients who remained in treatment more than 1 year. This finding was

consistent for most of the outcome measures tested (time until arrest, positive

parole discharge, reincarceration). Indeed, a multiple-regression analysis

confirmed a statistically significant decline in time until arrest for clients who

remained in treatment for more than 12 months. It should be noted, however,

that the clients in this group are still significantly less likely to recidivate than

those who terminate from the treatment in less than 9 months. In addition,

assessment of the possible influence of several psychological traits of the

clients did not produce significant or systematic associations between

measures of psychological traits and treatment outcomes. Furthermore,

the research design (utilization of treatment and no-treatment comparison

groups) adequately controlled for the subtle effects of motivation, deterrence,

and treatment. Thus, the robust central conclusion of the Stay’n Out research

is that hard-core drug abusers who remain in the prison-based TC longer are

more likely to succeed than those who leave earlier and that 9 to 12 months

appears to be the optimal duration for the treatment.

Cornerstone

The Cornerstone program is a highly respected treatment program for alcoholand drug-dependent offenders (for a detailed description, see Field 1985).

The program began in 1976 and is situated on the grounds of the Oregon

State Hospital in Salem. It consists of a 32-bed residential unit and a 6-month

aftercare program. Cornerstone is jointly administered by the Oregon Divisions

of Mental Health and Corrections.

Inmates are referred to the program by prison counselors. Admission criteria

require that candidates have a history of substance abuse, do not have a

history of psychosis or sex offenses, are at least 6 months but not more than

12 months from their parole, qualify for minimum security, and plan to remain

in the State after release. In 1984, Cornerstone clients had an average of

about seven felony convictions and had served more than 7 years in prison.

The mean age of first substance use was 12 years of age. Ninety-five percent

of the clients had histories of polydrug abuse.

Like Stay’n Out, Cornerstone is modeled on the TC concept. Two evaluation

studies of the Cornerstone program assessed several treatment outcomes,

including recidivism (Field 1985, 1989). The findings of both studies are

summarized here because they demonstrate the effectiveness of the program

over time. The first study (Field 1985) evaluated all clients who graduated

between 1976 and 1979 against three comparison groups: (1) clients who

19
dropped out in less than 1 month during the same timeframe, (2) all Oregon

parolees (from 1974 to 1977) who had a history of substance abuse, and

(3) a sample of Michigan parolees. There were no statistical differences

between the demographic characteristics of the program graduates

(n=144) and the dropouts (n=27). The group of Oregon parolees (n=179)

had significantly less severe histories of substance abuse and crime than

did the program graduates. The sample of Michigan offenders (n=217) was

based on a population similar in background to the Cornerstone groups.

A 3-year followup study compared the groups according to two outcome

measures: the percent not returned to prison and the percent not convicted

of any crime. The program graduates had a significantly higher success rate

for both outcome measures than each of the other groups. Seventy-one

percent of the program graduates were not reincarcerated 3 years after release

only 26 percent of the dropouts avoided reincarceration. Similarly, although

slightly more than half the program graduates were not convicted of any crimes

(including minor offenses), less than 15 percent of the dropouts were not

convicted of any crimes. As Field (1985) points out, the factors that cause

residents to drop out also may influence recidivism; however, the favorable

comparison with the other two groups supports the hypothesis that treatment

in the Cornerstone program is associated with reduced recidivism. Indeed,

Chi-square tests of both outcome measures showed that program graduates

had significantly better outcomes (p<.01) than the Oregon parole sample.

(Sixty-three percent of the parolees were not reincarcerated, and only 36

percent were not convicted of any crimes.) These univariate statistical

differences tend to understate the effect of the treatment because the

program graduates had significantly more severe criminal histories and

substance abuse problems.

Field’s second study (1989) produced similar results, using a different

research design. A group of program graduates (n=43) with an average

stay of 11 months in treatment was compared with three groups of clients

who did not graduate: (1) clients who spent more than 6 months in the

program (n=43), (2) clients who spent between 2 and 6 months in treatment

(n=58), and (3) clients who were in treatment for less than 2 months (n=65).

The measures of recidivism that were assessed in the 3-year followup include

the percent of each group without arrest, without conviction, and without

reincarceration (which included jail terms greater than 6 months as well as

prison sentences).

The results for the program graduates in this sample were quite similar to the

findings in the earlier evaluation. Slightly more than half the graduates were

not convicted and about three-quarters were not reincarcerated; in addition,

20
37 percent were not arrested. These results compared quite favorably to

the three groups that did not graduate. For example, 21 percent of the

nongraduates who were in treatment for more than 6 months were not

arrested; 28 percent of them were not convicted; and 37 percent were not

reincarcerated. The findings for the other dropouts are even more startling.

Only 8 percent of the clients who dropped out in less than 2 months were not

arrested during the 3-year followup; only 11 percent were not convicted; and

only 15 percent were not reincarcerated. These findings are consistent with

the findings in the Stay’n Out program, which showed that increased time in

program is associated with more positive treatment outcomes.

In addition to comparing the percent in each group that did not recidivate,

Field assessed the effect of the treatment on rates of recidivism, that is, the

average number of times that clients in each group were arrested, convicted,

and incarcerated. (These measures imply an expected probability of the

number of times that offenders will recidivate, depending on the amount of time

they spend in treatment.) The 3-year posttreatment period was compared with

two different 3-year intervals prior to the prison term that involved treatment

in the Cornerstone program. These intervals were the 36 months “at risk”

prior to the Cornerstone incarceration and the prior 37 to 73 months at risk.

(The at-risk intervals represent time in the community; they exclude time spent

incarcerated.) Because some subjects were too young to be at risk for 6 years

before the Cornerstone incarceration, only about 75 percent of the subjects in

each sample were included in this analysis.

The results of the analysis across the three recidivism rate variables were

consistent and support the findings on the variables that measured outcome

in terms of the percent of each group that did not recidivate. The arrest,

conviction, and incarceration rates for the group of program graduates were

lower than for each of the comparison groups. Furthermore, as the length of

time in treatment increased, recidivism rates declined. Perhaps the most

interesting findings pertain to the comparisons between the pretreatment and

posttreatment intervals. Whereas the recidivism rates during both pretreatment

intervals were about the same for each of the groups, recidivism rates during

the posttreatment period were considerably lower among the program

graduates. In addition, the decline in recidivism rates between the

pretreatment and posttreatment periods was greatest for the program

graduates.

These studies of the Stay’n Out program and the Cornerstone program are

the first large-scale research evaluations to provide solid evidence that

prison-based TC treatment can produce significant reductions in recidivism

rates among chronic drug-abusing felons. The cost-effectiveness of the

21
treatment makes the case for implementing such programs even more

imperative. Programs like Stay’n Out cost about $3,000 to $4,000 more

than the standard correctional cost per inmate per year. Programs such as

Cornerstone, with more professional staff and one-fourth the caseload per

staff member, cost a little more than twice as much for the same period. The

savings produced in crime-related and drug use-associated costs, however,

pay for the cost of the treatment in about 2 to 3 years.

Correctional drug treatment costs vary between $200 and $4,000 per inmate

per year above this (depending on modality form, length, and intensity) (Wexler

et al. 1990b). Such treatment is extremely cost-effective. That is, treatment

lowers crime and health costs as well as associated social and criminal justice

costs. Moreover, the higher the investment in rehabilitating the most severe

offender-addicts, the greater the probable impact. The most serious chronic

heroin and cocaine users (about 3 to 10 percent of all offenders, depending

on jurisdiction) are each responsible for 40 to 50 burglaries/year, 30 to 40

robberies/year, more than 1,000 drug transactions, etc. (Gropper 1985, based

on the work of Johnson et al. 1985; Ball et al. 1983; and lnciardi 1979). Any

substantial reduction in such criminality among this group immediately has an

impact on quality of life. Without intervention, this group will return to crime and

drug use 9 times out of 10 after release, and most will be back in custody within

3 years. With appropriate intervention, more than three out of four will succeed

(i.e., reenter the community and lead a socially acceptable lifestyle). This highly

predatory group is amenable to long-term (9 to 12 months) TC treatment while

incarcerated and is unlikely to benefit much from less intensive treatment.

PROSPECTS AND PROBLEMS IN PRISON DRUG TREATMENT

Dissemination of these results already has had an important impact on the field

and has generated interest as well as funding to support effective treatment for

substance abusers while in prison. In 1987, the Bureau of Justice Assistance

(BJA) of the U.S. Department of Justice funded NDRI, in the form of Project

REFORM, to provide technical assistance to State departments of correction

to help them plan statewide comprehensive drug abuse treatment strategies

for correctional inmates and implement the plans that developed. In the 2 years

that Project REFORM has been in operation, 11 State departments of

corrections (Alabama, California, Connecticut, Delaware, Florida, Hawaii, New

Jersey, New Mexico, New York, Oregon, and Washington) have received

technical assistance in developing (or enhancing) their comprehensive prisonbased drug abuse treatment systems from NDRl’s technical assistance and

training team. In the States that have completed at least 8 months of project

implementation (Alabama, Connecticut, Delaware, Florida, New Mexico, New

York, and Oregon), the number of drug abuse treatment system components

22
now operating as a direct consequence of NDRl’s technical assistance are as

follows: 39 assessment and referral programs implemented and 33 expanded

or improved; 36 drug education programs implemented and 82 expanded or

improved; 44 drug abuse resource centers implemented and 27 expanded

or improved; 20 in-prison self-help 12-step programs implemented and 62

expanded or improved; 11 urine monitoring programs and 4 expanded or

improved; 74 prerelease counseling and/or referral programs implemented

and 54 expanded or improved; 39 postrelease treatment programs with parole

or work release implemented and 10 expanded or improved; and 77 isolated

unit (milieu) treatment programs initiated and/or improved, including 16 brief

(less than 6 weeks), 19 short-term (6 to 12 weeks), 34 intermediate (5 to 9

months), and 8 long-term (9 to 15 months) treatment programs based on the

Stay’n Out and Cornerstone models (Wexler et al. 1990b).

There have been several TCs in correctional settings over the past two

decades. This particular intervention strategy was adopted by the correctional

community during the 1970s and several were started in State and Federal

prisons. However, most were abandoned after several years of operation and

their accomplishments and shortcomings were not documented systematically.

Of the 17 (of about 30 in all) TCs that have been closed since the 1970s, 11

were designed to serve drug offenders. Thirteen states are presently operating

TCs, and five are bringing them on-line-almost all to serve drug offenders

(Camp and Camp 1989).

An examination of TCs no longer in operation shows the earliest Federal

program began in 1969 at the Federal Penitentiary at Marion, IL; the oldest

State program began about the same time at Fort Grant in Arizona. The closed

programs ran for as short a period as 2 years and for as long as 9 years, with

an average of 6.5 years-which for correctional treatment programs is a long

period. It is revealing to discover the reasons for the demise of these programs.

Almost all the reasons for failure (staffing, prison administration, overcrowding,

budget cuts, and social conflict) were administratively circumstantial rather than

failures inherent in the concept of TCs.

Staffing is one of the keys to successful programing whatever the modality.

Motivated enthusiastic staff set the tone for the TC, which is a high-intensity

environment with demands put on staff for as long they are on-site. This

frequency and intensity of demand can lead to staff burnout and a resultant

high turnover rate that, in turn, leads to reduced program consistency and

stability, thereby undermining program integrity. This was a stipulated reason

for failure in several cases. Indeed, employment gaps require remaining staff

to do more, and running the program under these conditions strains the staff,

in turn, creating further turnover. Finding replacement staff is sometimes

23
difficult—recruiting recovered ex-offenders to go back to work in a prison is

trying under the best of circumstances. Moreover, they often do not share

the enthusiasm and experience of the original staff. Recovered persons, while

making excellent role models, are in need of support networks themselves. The

geographic isolation of some prisons makes keeping in contact with members

of their own support system onerous for recovered former offenders. This also

contributes to high turnover.

Another essential factor for a treatment program’s very existence and for its

success is the support of the prison administration. Changes in warden or

deputy administrator in charge of program was sufficient in several instances

to terminate well-functioning TCs. Such high-level administrative changes can

bring in administrators who are opposed to rehabilitation, view other forms of

treatment as more effective or more appropriate, want to use the program

space for a different purpose, or hold mistaken and prejudicial views about

TCs. When such changes in high-level administration occur, only the massing

of sufficient political influence and the weight of successful outcome and costeffectiveness data can prevent the program’s demise.

It is vital for a TC in a prison to have living space and therapeutic areas isolated

from the general prison population. Overcrowding seriously impinges on such

isolation. Program failures have occurred merely when the increase in the

prisoner population led to the need for housing reintegration with the general

population and when the increased numbers of addicts in need of treatment led

the administration to use the living space for programs that would treat much

larger numbers of persons.

Financial considerations often were a decisive factor in closing TCs.

Otherwise successful programs as well as only moderately successful

programs succumbed to agency-wide budget cuts. Unfortunately, yet

typically, when cuts in the correctional budget are required by the State

executive, the budget bureau, or the legislature, the first to go is research

and planning and the next is treatment programing.

TCs need to operate in a climate that accepts its activities and permits the

program a considerable degree of autonomy, while staying within the prison

rules. Differences in routine, jealousy about living arrangements or “special

privileges,” differences in temperament and world view, and the isolation of a

TC have contributed to social conflict in some prisons where TCs have existed.

For example, in one instance, the regular prison rehabilitation staff members

who were not involved with the TC were threatened by the self-help aspects

of the TC and sabotaged the program. Allegations of mysterious cult-like

activities and devil worship also have been reported where the TC program

24
failed to educate adequately the administration, staff, and general inmate

population about the program’s activities. When inmates fail in the TC, they

typically return to the general population where they are free to tell stories that

undermine the program’s reputation. In another instance, the emphasis on

open and honest communication in the TC was seen as a threat to the inmate

code of silence, resulting in confrontations tetween members of the general

population and members of the TC, which caused the administration to see

the TC as a source of problems.

The irony in so many of the failures is that the nature of the program that

makes it successful where it continues to operate is the cause of its demise.

Its isolation, its prosocial value system, its hierarchical incentive structure, its

self-help philosophy, and its open and honest communication seem to threaten

the entrenched inmate social system as well as the governance structures,

and these in turn can exercise sufficient influence to close a program. Of

course, in some instances poor management, poor leadership, inadequate

problemsolving, poor communication, bad staffing, and poor training have

contributed to program failures in some instances, but the data indicate that

these reasons are rare in comparison with budget cuts and administrative

changes (Camp and Camp 1989).

CONCLUSION

There are persons in senior policymaking positions as well as academics

who could not agree that rehabilitation is or should be one of the key purposes

of the postadjudicatory system. They would argue this on two bases: (1) It

lies outside the State’s responsibility, which is to punish and to deter (Allen

1981; Bartollas 1985; Currie 1985; Van den Haag 1975); and (2) correctional

rehabilitation does not work. Opponents of rehabilitation are able to marshal

potent quantities of data to support their point of view (Bailey 1966; Martinson

1974; Lipton et al. 1975) and also to blame ineffective rehabilitation for

increasing recidivism rates (Regnery 1985). However, there are a growing

number of people who hold a contrasting view, that is, that the “nothing works”

in corrections viewpoint is untrue and that there is ample evidence to support

rehabilitation as an effective crime control strategy (Gendreau and Ross 1979,

1981, 1984, 1987; Ross and Gendreau 1980; Greenwood and Zimring 1985;

Halleck and Witte 1977; Palmer 1978, 1986; Cullen et al. 1985; Van Voorhis

1987; Hamm and Schrink 1989; Andrews et al. 1990).

If it comes down to a matter of opinion as to whether the State has a

responsibility to undertake correctional rehabilitation, the authors firmly

declare for it. Some exponents do surveys of the public, legislators, and

policymakers and show that the bulk of concerned people express favorable

25
attitudes toward rehabilitation for offenders (Berk and Rossi 1977; Cullen

and Gilbert 1982) to convince the opposition that they are running counter

to public and professional opinion. But the encounter is with belief rather than

rationality. The authors assert the belief that the State has a responsibility to

encourage and sponsor rehabilitation for offenders.

Lipton (1990) argues that the objectives of the criminal treatment system are

to prevent crime and to prevent anomie. These objectives are implemented by

the postadjudicatory treatment system by administering sanctions that have

a sufficient degree of unpleasantness to demonstrate to the public that the

threats annexed to the prohibitions cannot be ignored without consequences

(i.e., general deterrence) and to reinforce the confidence of the public that the

State is determined to uphold norms through a demonstration of action taken

against offenders (i.e., prevention of anomie). A second way these objectives

are implemented by postadjudicatory treatment is by (1) preventing recidivism

through the use of sanctions as a vehicle for administering rehabilitative

techniques to bring offenders to the point where they voluntarily will observe

the prohibitions in the criminal law (i.e., rehabilitation), (2) preventive force

through incarceration or close community supervision of the offender so as

to limit his or her opportunity to offend again (i.e., incapacitation), and

(3) punishment to make the threats a reality to the individual offender so

that he or she will be more responsive to them in the future (i.e., individual

deterrence).

The authors hold further that rehabilitation is part of the social responsibility

of the postadjudicatory system as well as its legal responsibility and that this is

true particularly for the drug offender for whom custody in the postadjudicatory

treatment system provides control and opportunity exercised pursuant to

law. Custody is characterized by three factors: (1) restrictions on liberty not

applicable to the public at large; (2) coercive power for enforcement of the

restrictions; and (3) a tangible instrumentality for execution such as probation

or incarceration. Incarceration provides the setting and the opportunity for the

administration of rehabilitative programs; and three balanced purposes can and

should be effectively and simultaneously served: (1) punishment (individual

deterrence), (2) direct preventive force (incapacitation), and (3) retention for

prosocial change (rehabilitation).

Just serving time degenerates men and their keepers inexorably. Using time

as an opportunity for change values both of them and eventually alters the

quality of life for all humankind.

26
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eds. Crime Rates Among Drug-Abusing Offenders: Final Report to the

National Institute of Justice. New York: Narcotic and Drug Research, Inc.,

1986. pp. 81-104.

Ball, J.C.; Rosen, L.; Flueck, S.A.; and Nurco, D.N. The criminality of heroin

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Drugs-Crime Connection. Beverly Hills, CA: Sage, 1981. pp. 39-65.

Ball, J.C.; Shaffer, J.W.; and Nurco, D.N. Day-to-day criminality of heroin

addicts in Baltimore--A study in the continuity of offense rates. Drug Alcohol

Depend 12:119-142, 1983.

Bartollas, C. Correctional Treatment Englewood Cliffs, NJ: Prentice-Hall, Inc.,

1985.

Berk, R.A., and Rossi, P.H. Prison Reform and State Elites. Cambridge, MA:

Ballinger, 1977.

Camp, G.M., and Camp, C.G. Building on Prior Experiences: Therapeutic

Communities in Prisons. Internal Report to Project REFORM. South Salem,

NY: Criminal Justice Institute, 1989.

Chaiken, M.R. Crime rates and substance abuse among types of offenders. In:

Johnson, B.D., and Wish, E.D., eds. Crime Rates Among Drug-Abusing

Offenders: Final Report to the National lnstitute of Justice. New York:

Narcotic and Drug Research, Inc., 1986.

Chaiken, M.R. Prison Programs for Drug-Involved Offenders. Washington, DC:

National Institute of Justice, July 1989.

Chaiken, M.R., and Johnson, B.D. Issues and Practices: Characteristics

of Different Types of Drug-Involved Offenders. NIJ Research in Brief.

Washington, DC: National Institute of Justice, 1988.

Cullen, F.T.; Bynum, T.S.; Garrett, K.M.; and Greene, J.R. Legislative ideology

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Cullen, F.T., and Gilbert, K.E. Reaffirming Rehabilitation. Cincinnati, OH:

Anderson, 1982.

Currie, E. Confronting Crime: An American Challenge. New York: Pantheon,

1985.

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Program: An Evaluation of the “Stay’n Out” Therapeutic Community. Final

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Wexler, H.K.; Lipton, D.S.; and Johnson, B.D. A Criminal Justice System

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1986.

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January to March, 7989. Washington, DC: National Institute of Justice,

September 1989.

ACKNOWLEDGMENTS

The authors acknowledge the contributions of Nicholas Demos, Office of

Treatment Improvement, Alcohol, Drug Abuse and Mental Health

Administration, and John Gregrich and Kim Rendleson, BJA, U.S. Department

of Justice, for assistance in obtaining grant funding. This work was partially

supported by BJA, Office of Justice Programs, U.S. Department of Justice

grants 87-DD-CX-K060 and 88-DD-CX-008.

AUTHORS

Douglas S. Lipton, Ph.D

Director of Research

Gregory P. Falkin, Ph.D

Principal Investigator

Harry K. Wexler. Ph.D

Principal Investigator

Narcotic and Drug Research, Inc

11 Beach Street

New York, NY 10013

30
Program Models

Barry S. Brown

INTRODUCTION

There are five types of program models available for drug abusers in

correctional settings: (1) incarceration without specialized services,

(2) incarceration with drug education and/or drug abuse counseling,

(3) incarceration with residential units dedicated to drug abuse treatment,

(4) incarceration with client-initiated and/or client-maintained services,

and (5) incarceration with specialized services that do not directly target

users’ drug abuse problems.

Although this chapter focuses on these five models, three additional

alternatives also target the drug-abusing offender: (1) routine probation,

(2) surveillance-only initiatives, and (3) use of Treatment Alternatives to

Street Crime (TASC).

MODELS IN CORRECTIONAL SETTlNGS

Incarceration Without Specialized Services

The model most commonly available to the imprisoned drug abuser is

incarceration without a specialized program. A 1987 survey (Chaiken 1989)

of correctional program directors in the 50 States suggests that only 11.1

percent of inmates in State institutions were enrolled in specialized drug

programs in that year, up from the 4.4 percent reported in a National Institute

on Drug Abuse survey (National Institute on Drug Abuse 1981)—hardly a figure

that gives comfort to those who see treatment interventions as important in

containing recidivism in this population. A very conservative approach would

target only those 140,000 individuals in State correctional facilities who, in a

1986 survey (Innes 1988) were reported to be frequent users of heroin, street

methadone, cocaine, phencyclidine (PCP), or LSD immediately before arrest.

Even with this conservative approach, the 51,500 people reportedly seen in

some form of drug abuse treatment in 1987 would represent little more than a

third of the population in need.

31
The lack of specialized drug abuse treatment does not translate into a lack of

rehabilitative services. Depending on institutional resources, such initiatives as

educational programing, vocational counseling, casework services, release

planning, and individual and/or group counseling may be available. To the

extent these services are available, they typically are provided by institutional

personnel, although some workers (e.g., teachers) may be contracted through

the local community. Services are available through staff direction or at the

instigation of the correctional client.

Incarceration With Drug Education and/or Drug Abuse Counseling

The second most common model of drug abuse treatment involves drug

education and/or targeted counseling, including (as above) the range of

traditional rehabilitative services that a correctional facility’s resources permit.

In addition, efforts are made to make drug-abusing offenders more aware of the

consequences of their drug-taking behaviors and the risks thereof. The sudden

and dramatic emergence of acquired immunodeficiency syndrome (AIDS) as

a threat to life among intravenous (IV) drug users lends new, if unwelcome,

weight to these arguments. Institutional settings are focusing more attention

on this aspect of drug use and, in some instances, developing innovative

educational strategies to arouse concern and encourage behavioral change.

In this model, individual and/or group counseling also is used to focus on drug

abuse issues. According to Chaiken (1989), group counseling has become the

favored approach. Counseling strategies involve usual efforts at uncovering

resistances and lending support to behavior change initiatives. In addition,

group efforts may make substantial use of confrontational strategies, derived in

part from the experience of the therapeutic community, while also employing the

group to provide encouragement and assistance to correctional clients’ efforts

to modify their thinking and behaviors. Thus, the group operates as a spur and

a support to behavior change.

Treatment services in this model are provided by institutional staff—

caseworkers or psychologists-and are funded through departmental budgets.

These programs and all other treatment and rehabilitative programs provided

on institutional grounds operate at the sufferance of security personnel. This is

not to say that support for treatment and rehabilitation is lacking, particularly as

one moves along the continuum from maximum to minimum security, but that

all service providers in institutional settings eventually come to understand the

dominance of and the need to pay sufficient attention to security issues to

guarantee support for service initiatives.

32
Incarceration With Dedicated Residential Units

The third model involves incarceration with use of residential units dedicated

to drug abuse treatment. These units may exist as distinct programs within

the larger correctional facilities, such as New York’s Stay’n Out therapeutic

community (TC) program, Wisconsin’s Drug Abuse Treatment Unit, and

Florida’s Lantana program; or they may be organized as secure units outside

the correctional complex, such as the Cornerstone program located on the

grounds of the Oregon State Hospital made infamous in the movie “One Flew

Over the Cuckoo’s Nest” (Chaiken 1989; Bureau of Justice Assistance,

unpublished manuscript). Arguably, the use of alternative secure sites for

treating drug abusers has its historical roots in the Lexington (Kentucky) U.S.

Public Health Service Hospital, which opened in 1935.

Current residential units are modeled on the structure and functioning of TCs.

Some units, such as Wisconsin’s Drug Abuse Treatment Unit, closely resemble

the traditional version of the TC, employing “pull-ups” (verbal reprimands) by

fellow residents or staff, as well as wearing signs or carrying oversize items

that serve as negative reinforcers. TCs use the group and the setting to

stimulate and reward growth, as evidenced by taking increased responsibility.

The resident is expected to play an increasing role in the maintenance of the

environment, in the behaviors and functioning of fellow residents, and in the

adoption of changed and more mature behaviors on his or her part. In addition

to use of the milieu and group as stimuli to change, there is some mix of

encounter sessions, group counseling, large group (community) sessions,

individual counseling, and traditional rehabilitative programs (such as

educational efforts and vocational counseling). Status in the community is

associated with the degree to which the individual undertakes change and

accepts responsibility for stimulating change in others.

Staff may be drawn from the ranks of the corrections department (e.g., Lantana

and Wisconsin’s Drug Abuse Treatment Unit) or from outside the correctional

setting (e.g., Stay’n Out and Cornerstone). Whether they are service providers

or correctional personnel, staff persons attached to these programs appear

to regard themselves as special, pursuing a kind of mission separate from the

initiatives of their correctional colleagues. The staff may represent backgrounds

that are different from those of other corrections service providers. Most

dramatically, the Stay’n Out program employs recovering addicts on its staff,

whereas convicted felons are frequently unable to gain employment in other

correctional settings.

Funding also may come from diverse sources-from the corrections department

alone or from a mix of corrections, drug abuse, and/or mental health programs.

33
Federal funding, as seed money to help initiate a combined research and

services initiative, may be a possibility through demonstration grant money

Incarceration With Client-Initiated and/or Client-Maintained Services

The fourth model involves programs initiated and/or maintained by clients.

In this model, clients take primary responsibility for initiating drug-oriented

behavior change programs within the institution. Narcotics Anonymous (NA),

for example, is organized within correctional settings, often with the assistance

of interested correctional staff. Pamphlets and materials are available from

NA headquarters, which can help guide the planning, implementation, and

maintenance of an NA program. The NA headquarters also maintains a list

of all NA programs organized by location.

NA’s 12-step program is designed to lead to a drug-free lifestyle and to the

addicts becoming acceptable, responsible, and productive members of society.

Institutional NA programs frequently draw on sympathetic NA members of the

neighboring community who share aspects of correctional clients’ backgrounds

and can be enlisted to speak at NA meetings as well as provide links to the

community and evidence of support and concern within that community.

Little is known about the structure and functioning of NA programs in

correctional settings, perhaps because professionals are less likely to develop

them or to be an integral part of them. Nonetheless, they offer an inexpensive

support to a changed, drug-free lifestyle that seems worthy of attention from

the drug abuse and criminal justice fields.

Another “program” that significantly targets drug use and is entirely “clientdriven” is adoption of the Muslim faith and its practices. Again, relatively little

information exists on the role and influence of Muslims vis-a-vis drug abuse

and behavior change. Only anecdotal data exist with regard to in-prison

conversions and group influence; this issue also merits closer attention.

These client-driven programs make minimal demands on staff and resources,

although the correctional staff may undertake some coordinating responsibilities

with both NA headquarters and the local free community on behalf of the NA

chapter. According to some reports, both NA and Muslim activities are viewed

positively by correctional staff, at least in part because of the capacities of both

groups-particularly the Muslim followers-to maintain peace in the correctional

community.

34
Incarceration With Specialized Services for Problems Other Than Drug

Abuse

The fifth model involves the use of specialized services for drug abusers

that do not directly target drug abuse problems. The Simon Fraser Prison

Education Program organized by Simon Fraser University in Vancouver,

British Columbia, is located in four correctional institutions (Chaiken 1989).

The program provides collage-level study in a degree program to offenders

who are willing to commit to the self-discipline required to undertake a course

of study. Most, but not all, of the prisoner student body have histories of longterm drug abuse. A part of the Simon Fraser program involves the award of

certificates in literacy training, enabling program students to teach reading and

writing to their illiterate peers in the correctional institutions.

As in the case of earlier college training programs for prisoners and the Daytop

Village’s TC college program targeting drug abusers (Biase 1989) the success

of the Simon Fraser program in containing client recidivism is due in part to

the personal resources and capabilities of those clients eligible for a college

program. Nonetheless, the importance of providing programs to channel and

support individuals’ capacities should not be denigrated, especially when those

programs achieve their objectives. Staff and resources for the Simon Fraser

program are derived from sources outside the correctional department and

institutions.

MODELS OUTSIDE CORRECTIONAL SETTINGS

Whereas the foregoing five models provide drug abuse treatment for clients

within institutions, three other models of service delivery involve alternatives

to incarceration.

Probation

The most typical model of service delivery to correctional clients is probation,

a mix of counseling, support, and surveillance. Nearly two-thirds of all

adjudicated offenders are placed on probation; and the probation population

is growing even more rapidly than the incarcerated population, albeit without

comparable growth in human and material resources (Byrne et al. 1989).

Surveillance

To meet the challenge of increasing numbers of offenders, there also is an

increasing interest in and use of surveillance-only mechanisms to deliver

services to nonincarcerated offenders. Although house arrest and electronic

35
monitoring, for example, are unconcerned with providing rehabilitative services

(and in the case of 24-hour house arrest would appear inimical to rehabilitative

ends), these strategies are appealing as appropriate techniques for monitoring

and controlling client movement outside correctional settings. About 10,000

offenders have been placed under house arrest (Byrne et al. 1989) and 2,300

on electronic monitoring (Schmidt 1989), although the latter technology is

reportedly gaining attention.

Treatment Alternatives to Street Crime

A third model of service delivery as an alternative to criminal justice programing

is TASC (Weinman, this volume), which involves diversion from criminal justice

processing into a program that provides a mix of supervision and treatment

services.

As do probation and surveillance-only programs, TASC has one objective

(and selling point): relief of jail and prison overcrowding. Unlike the other two

programs, TASC is vitally concerned with providing linkages to community

treatment programing and, through those linkages, with making rehabilitative

opportunities available to drug-involved offenders (Bureau of Justice Assistance

1988).

CONCLUSION

These efforts to contain drug use-specifically IV drug use-have received

increased impetus by virtue of their significance in containing the spread of

AIDS. Given the role and potential of the IV drug-using population in the

spread of that disease, efforts taken to encourage the use of effective models

can be central to the survival of thousands and perhaps tens of thousands of

persons. At the same time, these models must be refined and tested, and

additional effective models must be encouraged. Although corrections

professionals generally are good at conducting studies, they are sadly

deficient in encouraging and supporting the use of study findings. With

respect to AIDS, such a deficiency could be tragic.

REFERENCES

Biase, V. “Daytop’s College Education Program.” Paper presented at the What

Works Conference, New York, 1989.

Bureau of Justice Assistance. Treatment Alternatives to Street Crime, TASC

Programs. Washington, DC: Department of Justice, 1988.

Byrne, J.M.; Lurigio, A.J.; and Baird, C. The effectiveness of the new intensive

supervision programs. Res Corrections 2:1-48, 1989.

36
Chaiken, M.R. In-Prison Programs for Drug-Involved Offenders. Washington,

DC: National Institute of Justice, 1989.

Innes, CA. Profile of State Prison Inmates, 1986. Washington, DC: Bureau of

Justice Statistics, National Institute of Justice, 1988.

National Institute on Drug Abuse. Drug Abuse Treatment in Prisons. DHHS

Pub. No. (ADM)81-1149. Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental

Health Administration, 1981.

Schmidt, A.K. Electronic monitoring of offenders increases. In: NIJ Reports.

Washington, DC: National Institute of Justice, 1989. pp. 2-5.

AUTHOR

Barry S. Brown, Ph.D.

Chief

Community Research Branch

Division of Applied Research

National Institute on Drug Abuse

Parklawn Building, Room 9A-42

5600 Fishers Lane

Rockville, MD 20857

37
Drug Treatment Services in Jails

Roger H. Peters and Robert May II

INTRODUCTION

Jail and prison populations have grown considerably in the past several

years as a result of an influx of new arrestees who are involved with drugs.

Sixty-two percent of State and Federal prisoners report regular drug use prior

to incarceration (Frohling 1989). The proportion of drug-dependent jail inmates

also has risen steadily. Information from the Drug Use Forecasting (DUF)

system reveals that over 70 percent of arrestees in many metropolitan areas

test positive for drugs (U.S. Department of Justice 1989).

Treatment resources for drug-dependent jail and prison inmates have not kept

pace with the demand for services. State correctional administrators report

that from 70 to 80 percent of inmates are currently in need of drug treatment

(Frohling 1989). Despite evidence that participation in State correctional drug

treatment programs is increasing (Chaiken 1989), only 6 percent of State prison

inmates sampled in a recent survey reported that they were currently enrolled in

drug treatment (U.S. Department of Justice 1988). For inmates referred to injail drug treatment, only 11 percent reported prior treatment for alcohol abuse

and 31 percent for other drug abuse (Peters and Dolente, unpublished data).

Treatment in a correctional setting provides an important opportunity to

engage offenders in a therapeutic environment who otherwise would not

seek treatment on a voluntary basis or who have a poor record of treatment

participation (Wexler et al. 1988). For many offenders, incarceration is the first

lengthy period of abstention since initiation of regular drug use and provides an

enforced removal from drug-using peers, family conflict, or other cues that often

precipitate drug use. For incarcerated offenders, motivation to participate in

treatment is enhanced by the immediacy of negative consequences of past

drug use. Correctional drug treatment enables offenders to begin developing

life skills and drug coping skills, and it serves as a foundation for subsequent

involvement in community-based treatment.

Drug treatment in a correctional setting provides an effective vehicle to prevent

offenders from returning to chronic patterns of drug abuse and crime. Within

38
this setting, court-ordered treatment programs have been shown to encourage

involvement in drug treatment for offenders who are unlikely to attend such

programs on their own (Anglin 1988). Offenders who are court-ordered to

drug treatment experience short-term treatment outcomes that are comparable

to those of voluntary clients (Maddux 1988; Simpson and Marsh 1988), and

they often remain in treatment longer than clients without criminal justice

sanctions (Hubbard et al. 1988). Treatment retention among offenders released

from correctional treatment programs is strengthened by ongoing supervision

and monitoring provided by Treatment Alternatives to Street Crime (TASC)

programs (Collins and Allison 1983; Hubbard et al. 1988). Increasing retention

in community-based treatment tends to reduce daily drug use and involvement

in criminal activity among drug-dependent offenders. Several studies indicate

that involvement in correctional drug treatment reduces the likelihood of criminal

recidivism. Findings from a followup of offenders participating in the Stay’n Out

program in New York (Wexler et al. 1990) indicate that inmates who completed

the treatment program had significantly fewer parole violations than those

who dropped out before completing treatment or those who participated in less

intensive programs. A similar followup of participants in the Cornerstone

Program in Oregon (Field, this volume) found that, over a 3-year postrelease

period, program graduates were significantly less likely than other participants

who did not complete the program to be arrested, convicted, or placed in prison.

For inmates treated in the Wisconsin Department of Corrections’ Drug Abuse

Treatment Unit (DATU), only 6 percent of program participants returned to State

prison during a 2-year followup period, compared with 33 percent of untreated

inmates (U.S. Department of Justice 1990).

This chapter examines the scope of drug treatment services in jails across the

country, as addressed by a recent survey conducted by the American Jail

Association. Several innovative treatment approaches implemented by in-jail

model demonstration programs also are reviewed. The success of these

approaches is discussed within the context of preliminary evaluation findings,

including indications of progress during treatment and of recidivism following

release from in-jail programs.

NATIONWIDE SURVEY OF IN-JAIL DRUG TREATMENT PROGRAMS

Although several studies (U.S. Department of Justice 1989; Peters and Dolente,

unpublished data) have documented the prevalence of drug abuse among

jail inmates and the low proportion of inmates who have received treatment,

program-level survey data addressing the quantity and quality (e.g., content)

of in-jail drug treatment programs have not been systematically collected. The

Drug Treatment Program Survey, conducted by the American Jail Association,

has provided the first comprehensive examination of in-jail drug treatment

39
programs in this country. The survey was conducted as part of a larger

initiative funded by the U.S. Department of Justice, Bureau of Justice

Assistance (BJA), entitled “Drug Treatment in the Jail Setting: A National

Demonstration Program.” The American Jail Association was selected to

administer this grant program and also has assisted in the development of

three model demonstration in-jail drug treatment projects.

The Drug Treatment Program Survey examined important aspects of the

jail facility and population and identified key components of drug treatment

programs, including staffing patterns, number of inmates served, length of

stay in the program, and type of treatment offered. Survey respondents were

asked to describe the status of existing in-jail drug treatment programs in 1987.

Survey results were based on a total of 1,737 respondents from 48 States and

the District of Columbia, representing 57 percent of all jails in the country. Each

geographical region of the country was adequately represented in the survey,

with respondents about evenly split between Eastern and Western States.

Only 28 percent of jails responding to the survey offered drug treatment

services other than detoxification. As indicated by table 1, jails with fewer

than 50 inmates were particularly underrepresented among facilities with drug

treatment programs, with only 15 percent currently providing such services.

For jails with drug treatment programs, 33 percent reported that services were

provided by volunteers. Thus, funded drug treatment programs were present in

only 19 percent of jails surveyed. An additional 116 jails (9 percent) planned to

implement a drug treatment program within 6 months. For jails without a drug

treatment program (n=1,186) and with no plans to implement a program in the

following 6 months, 65 percent indicated that development of services was

hindered by a lack of funds. Another 29 percent reported a lack of need for

drug treatment services. Jails with fewer than 250 inmates accounted for 93

percent of all respondents that indicated difficulties in funding drug treatment

services and 97 percent of respondents that indicated a lack of need for these

services.

Characteristics of Drug Treatment Programs

Drug treatment programs were isolated from the general inmate population

in only 12 percent of jails, including fewer than 4 percent of all programs in jails

with fewer than 250 inmates. Forty-two percent of drug treatment programs

were located in jails using the direct supervision model of inmate management.

Only 30 percent of jails without treatment programs used the direct supervision

concept. Jails with drug treatment programs were substantially larger

(average daily nonpeak population=327 inmates) than jails without programs

(average=68 inmates). The average drug treatment program size was 42

40
TABLE 1.

Drug

Treatment

Services

Drug

treatment

program*

Group

counseling

Transition

planning

Drug

Drug treatment services by size of jail for all survey respondents

Fewer than

(n=1,014)

15

50-250

(n=440)

41

Number of Inmates (Percent)

251-499 500-999 1,000-2,000

(n=103) (n=57) (n=32)

60 67 72

6 20 43 47 58

2 11 31 32 33

6 19 42 46 55

education

Comprehensive

program†

2 9 28 32 35

Volunteer 6 15 13 16 9

services only

Program

planned within

6 months

5 14 20 22 39

More than

2,000 Total

(n=15) (n=1,647)

67 26

60 15

53 8

60 14

53 7

27 10

20 9

*Other than detoxification services

†Program includes group counsellng. drug education, transition planning, and referral to outside treatment

agencies.

inmates (SD=69) but varied considerably according to the size of the jail

system. In general, larger jails had a larger drug treatment population. For the

56 drug treatment programs in jails of over 500 inmates, the average program

size exceeded 70 inmates. Inmate requests to participate in drug treatment

programs exceeded the number of slots available for all categories of jail size.

Survey respondents indicated that only 39 percent of inmates who participated

in an in-jail drug treatment program during 1987 actually completed the

program, although it was unclear what proportion of this total had been

discharged involuntarily.

Inmates enrolled in drug treatment programs averaged 26 years of age. For all

programs surveyed, 66 percent of participants were white, 23 percent black, 8

percent Hispanic, and 3 percent of other ethnic backgrounds. Programs in

larger jails tended to have greater numbers of black and Hispanic participants.

The proportion of sentenced inmates in jails with drug treatment programs (48

percent) did not differ significantly from jails without programs.

41
In-jail drug treatment programs employed an average of three staff members,

with a range of two employees for jails of fewer than 50 inmates (average

program size=17) to a high of six staff members for jails with more than 2,000

inmates (average program size=171). The ratio of paid program staff members

to inmates enrolled in drug treatment averaged 1:12 for all jails responding

to the survey. The most favorable staff to inmate ratio (1:6) was reported by

jails of fewer than 50 inmates. The least favorable ratio (1:25) was reported

for jails of over 2,000 inmates. More than 80 percent of programs used

community volunteer services. The number of volunteer staff members

exceeded the number of paid personnel across all categories of jail size.

In-jail drug treatment programs averaged 6.5 volunteers, or more than twice

the number of paid staff. Use of volunteers increased according to the size of

the jail population. Of all programs surveyed, jails of over 500 inmates were

the most reliant on volunteers, with an average of at least two volunteers for

every paid staff member. In-jail drug treatment program coordinators were

from a wide range of mental health and social services backgrounds, including

psychologists (19 percent), psychiatrists (8 percent), social workers (31

percent), and drug specialists (30 percent).

Treatment Interventions

For the 28 percent of jails (responding to the survey) that had drug treatment

programs other than detoxification services, the most common treatment

interventions were group counseling (78 percent), individual counseling (78

percent), drug education (76 percent), and referral to outside agencies (84

percent). Only 44 percent of in-jail programs provided transition planning

prior to release. For jails of fewer than 50 inmates, only 26 percent provided

transition planning. Existing in-jail drug treatment programs included

approximately 6 hours of therapeutic activities per week for each inmate.

The number of hours of programing increased as a function of jail size, with

treatment programs in jails of over 1,000 inmates averaging over 13 hours of

treatment activities per week.

Attempts were made to identify in-jail drug treatment programs that provided

a comprehensive level of services. A criterion measure for comprehensive

treatment was established that included provision of each of the following

services: (1) group counseling, (2) drug education, (3) transition planning,

and (4) referral to outside treatment agencies. According to this measure,

only 107 (7 percent) of all jails surveyed provided a comprehensive level of

drug treatment services. Comprehensive drug treatment programs averaged

6.8 hours of inmate activities per week compared with 3.8 hours per week

provided by noncomprehensive programs. However, only 19 of the jails with

comprehensive drug treatment programs (17 percent) and only 11 jails without

42
comprehensive programs (6 percent) provided more than 10 hours per week

of treatment activities. The number of hours of treatment programing

appeared to increase according to the size of the jail for both comprehensive

and noncomprehensive programs. Drug treatment programs within larger jails

also appeared to be more comprehensive with respect to provision of group

and individual counseling, drug education, and transition planning.

In Jail Drug Treatment Program Costs

Program costs varied enormously, even within jails of approximately the same

size. It is unclear to what extent these differences are attributable to the use

of different methods for determining costs. Fewer than one-third of jails with

drug treatment programs reported actual program costs. For these jails,

costs per year averaged $74,450, with a range of $13,042 for jails with less

than 50 inmates to $233,080 for jails housing from 1,000 to 2,000 inmates.

Expenditures for each inmate enrolled in drug treatment programs averaged

$4.90 per day in addition to normal incarceration costs. This figure was derived

using average yearly program costs and average program capacity, and it is

based on the assumption that in-jail programs operated at 100-percent capacity

during the reporting period. Average daily inmate costs ranged from $2.30 for

jails of 500 to 999 inmates to $9 for jails of 1,000 to 2,000 inmates. Program

costs varied as a function of jail size, the number of hours of treatment activities

provided per week, and the number of treatment interventions provided. Over

70 percent of jails surveyed received funding for drug treatment programs from

the county government. More than 40 percent of jails received State funding.

Adjunctive Drug Treatment Services

Survey results indicate that several adjunctive drug treatment program

activities are provided in jails. For all jails sampled, 22 percent provided

detoxification services, 77 percent provided intake screening for drug abuse,

and 76 percent provided intake medical screening. Only 3 percent of all jails

conducted drug testing at the time of intake, and 13 percent provided random

urinalysis during incarceration. Six percent of respondents indicated that

acquired immunodeficiency syndrome (AIDS) screening was provided at

intake. A larger proportion (37 percent) of jails provided AIDS testing after

intake, although this was presumably done on a selective basis according to

need. Almost two-thirds of jails reported specialized training for correctional

officers in substance abuse-related topics, and 57 percent provided training in

AIDS screening. In general, large jails were more likely to report the availability

of adjunct drug treatment services.

43
MODEL DEMONSTRATION PROGRAMS

Several comprehensive in-jail drug treatment programs have been developed

through a 1987 grant from BJA and administered by the American Jail

Association. Three model demonstration projects were developed-in

Hillsborough County (Tampa), FL; in Cook County (Chicago), IL; and in

Pima County (Tucson), AZ. These programs were developed to disseminate

information regarding strategies for implementing treatment programs in a

jail setting, effective treatment approaches, and evaluation of treatment

effectiveness. The model demonstration programs have hosted several

training sessions and provided consultation for jail staff interested in

developing similar drug treatment programs.

Treatment Approaches

Although the treatment approaches vary, each program provides

comprehensive assessment, drug education, group and individual counseling,

vocational and educational activities, and case management services, including

work to develop a followup treatment plan and linkage with the courts and

with community drug treatment providers. The in-jail program in Florida

provides services to 70 inmates, most of whom are sentenced. Treatment

services are provided to both male and female inmates. The 6-week treatment

curriculum includes an emphasis on the development of cognitive-behavioral

and relapse prevention skills. Inmates remaining in jail for more than 6 weeks

are enrolled in an advanced skills group. Relapse prevention efforts focus on

identification of specific antecedents to relapse and of high-risk situations, on

rehearsal of coping skills to manage high-risk situations, and on returning to

abstinence following a single lapse to drug use. Other interventions address

need to restore lifestyle balance, to manage anger and stress, to develop

communications skills, and to build a long-term plan for recovery.

The programs in Arizona and Illinois use therapeutic community (TC)

approaches. The program in Arizona treats approximately 50 sentenced

inmates in a modified TC setting within a direct supervision pod. The

average length of stay in the drug treatment unit is 6 months. The treatment

unit recently admitted female inmates, which has encouraged more open

communication among group members and more rapid changes in prosocial

attitudes and behaviors. Following release from jail, most inmates are referred

to a full-time residential facility or to other less intensive levels of community

treatment. The program in Illinois is based on the principles of Alcoholics

Anonymous/Narcotics Anonymous 12-step approach programs and provides

services to pretrial inmates in four (40-bed) direct supervision dormitories,

The program relies significantly on inmate leadership and monitoring of

treatment activities.

44
A major objective of each of the model demonstration programs is to provide a

graduated reentry to the community, with the goal of assisting the offender to

remain abstinent from drugs during the critical first several months following

release from jail. The programs in Florida and Illinois are assisted by TASC

counselors who work with inmates to develop a followup treatment plan, to

ensure that an initial appointment for community treatment is made, and to

monitor offender participation in followup treatment. TASC programs also

provide key linkages to assist the court in designating appropriate followup

treatment as a condition of probation. In the Florida program, the TASC

counselor provides an intake assessment for the community treatment provider

during the last week of participation in the jail program, thus streamlining the

process of enrollment in community treatment. In the Arizona program, where

treatment services are subcontracted to a community agency, coordination of

followup care is provided by the primary treatment counselor.

Evaluation Results

Preliminary evaluation results from the model demonstration programs indicate

that offenders involved in drug treatment show marked improvements in

knowledge of key aspects of the treatment curriculum, in abilities to use drug

coping skills, and in psychological functioning. Several repeated measures

administered in the Florida program provide evidence of progress over the

course of treatment in use of skills to manage high-risk situations for drug

relapse. A sample of 207 inmates were administered the Problem Situation

Inventory (PSI) (Hawkins et al. 1986), a situational competency test designed to

examine coping skills in high-risk situations. Evaluation results demonstrated a

significant increase in PSI test scores at the time of program completion. The

mean pretreatment PSI score was 42.3 compared with a posttreatment mean of

63.5 (t[207]=13.49, p<.001). Results indicated significant improvements in

abilities to respond (albeit in a simulated setting) to situations that frequently

lead to drug use following release from treatment.

Inmates in the Florida program also are administered a substance abuse

test to evaluate knowledge gained over the course of treatment, including

relapse prevention principles, information regarding the stages of recovery,

and coping skills for use in high-risk situations. Test scores were found to

improve significantly over the course of treatment. The mean pretreatment

test score was 57.4 compared with posttreatment score of 82.3 (t[232]=23.17,

p<.001). Particular improvement was noted in areas related to identification

of personal high-risk situations, abilities to identify urge coping skills, and

identification of methods for disputing irrational beliefs related to drug use.

Repeated evaluation measures administered in the Arizona program indicate

substantial improvement in psychological functioning over the course of drug

treatment as measured by reductions in anxiety and depression.

45
Preliminary results from a 1-year followup of program participants released

from the model demonstration program in Florida indicate that the length

of involvement in treatment is inversely related to the likelihood of rearrest.

Inmates successfully completing the 6-week treatment program in Florida

(n=31) were about half as likely to be rearrested during the first 3 months after

release compared with offenders who had been terminated from the program.

For inmates completing the program, 23 percent were rearrested within 3

months, 42 percent within 6 months, and 61 percent 1 year after release from

jail. In other words, 39 percent of program completers were not rearrested

within 1 year. In contrast, 70 percent of inmates prematurely released from

treatment (due to release on bond or recognizance; n=23) and 79 percent of

inmates terminated from the treatment program (n=24) were rearrested during

the 1-year followup period. Inmates completing the program averaged one

arrest during the followup period, a slight reduction compared with the rate of

arrest in the year prior to their last incarceration (mean=1.6 arrests). Inmates

who were released prematurely or who were terminated from the program were

arrested at about the same rate during pretreatment and followup periods.

Several caveats should be addressed before interpreting followup results:

(1) A primary consideration is the extremely small sample size. Continued

efforts to track program participants will enhance generalizability of these

results. (2) This sample includes offenders who are at extremely high risk for

reinvolvement with drugs and criminal activity due to considerable prior contact

with the criminal justice system and who have had little prior involvement in

treatment. Offenders in the Florida program averaged 6.3 prior arrests and

1.2 years of incarceration; they also had an average of less than one prior

episode in drug treatment. (3) It also should be noted that the Florida sample

received treatment within 6 months of program startup, at a time of considerable

change in the treatment curriculum and of staff turnover. Within 6 months afler

this first sample of participants was released from jail, daily group counseling

sessions were expanded from 1 to 2 hours per day; the treatment curriculum

was revised to include several new interventions; and a TASC counselor was

assigned to assist in placing inmates in community drug treatment programs.

Additional tracking efforts will be required to determine whether these

programmatic changes are related to improvement in psychosocial functioning

during treatment and to reductions in rearrest following completion of the

program.

CONCLUSION

Despite the high prevalence of drug abuse among inmate populations, and a

growing awareness that untreated drug abusers have a negative impact on all

segments of society, most jails do not have adequate drug treatment services.

For the 1,687 jails that provided information regarding inmate census, only

46
12,894 inmates (7 percent) of an average daily inmate population of 192,461

were enrolled in drug treatment programs. Even for jails with drug treatment

programs, only 12,894 (13 percent) of 100,389 inmates were involved in

treatment. The absence of drug treatment services is particularly striking in

smaller jails. The survey identified a clear need for smaller jails to begin forging

linkages with community drug treatment providers or to hire in-house staff to

provide at least minimal treatment interventions such as drug education and

group counseling. Survey findings point strongly to the conclusion that only a

small fraction of inmates needing drug treatment in 1987 actually received these

services.

Drug treatment programs were more likely to be reported in large jails, in jails

with a continuum of adjunctive support services (e.g., screening, urinalysis,

training, collection of assessment data), in jails with an orientation toward

development of inmate and staff (e.g., employee assistance) programs, and in

jails with an orientation toward innovative approaches to inmate management

(e.g., direct supervision). Only 19 percent of all jails surveyed reported a drug

treatment program supported by paid staff. Many of these programs do not

appear to provide an adequate level of drug treatment services: (1) 75 percent

do not provide group therapy, drug education, transition planning, and referral

to community drug treatment agencies; (2) only 30 programs (2 percent of all

survey respondents) provide more than 10 hours per week of treatment

activities: (3) programs average only three paid staff members; and (4) only 12

percent of drug treatment programs presently isolate participants from the

general inmate population. A significant concern is the absence of transition

planning/case management services, available in only 8 percent of jails

surveyed. Without strong efforts to place offenders in followup care in the

community, it appears unlikely that in-jail programs will be effective.

The absence of in-jail drug treatment services represents a neglected

opportunity to assist offenders in developing skills to prevent further relapse to

drug use. Jail inmates spend a considerable number of idle hours that would be

spent more productively in drug treatment. Survey results indicated that over

half of all sentenced offenders (representing an average of 47 percent of jail

populations sampled) were incarcerated for at least a month and that 32

percent were incarcerated for over 3 months. Evaluation results from jail and

prison programs indicated that treatment of incarcerated inmates was an

effective means to develop skills critical to the recovery process and to reduce

subsequent drug use and rearrest.

In comparison with residential treatment in the community, the costs of

developing and operating an in-jail drug treatment program are quite modest.

Survey results indicated that jails rated as having comprehensive programs

47
provided drug treatment services for 7 hours a week (per inmate) for an

average of 65 inmates, at an average cost of $83,574 per year. This average

program cost translates to $3.50 per day, per inmate, beyond the ordinary cost

of incarceration.

Technical assistance and consultation in staff training, treatment curriculum

development, and assessment and evaluation are critically important in

developing new in-jail drug treatment programs, particularly in jails with no

services. Without this support, it appears likely that jails will continue to take

a disjointed approach in program development and to rely on volunteers and

may neglect key program components such as thorough screening and

assessment, group counseling, and transition planning.

Preliminary findings from model demonstration drug treatment programs in

jails indicate that even relatively short-term interventions (6 to 8 weeks) can

provide inmates with important coping skills to manage high-risk situations and

can increase the fund of knowledge regarding the recovery process, healthrelated consequences of drug abuse, and relapse prevention principles. In-jail

programs based on development of cognitive-behavioral skills appear to hold

considerable promise in reducing the rate of rearrest following release from

jail. Further research is needed to explore (1) the long-term impact of in-jail

drug treatment programs, (2) specific interventions that are most effective for

drug-dependent inmates, (3) the effect of varying lengths of in-jail treatment,

(4) innovative community-based followup interventions such as use of

employment incentives, and (5) predictors of success in jail drug treatment

programs.

REFERENCES

Anglin, M.D. The efficacy of civil commitment in treating narcotic addiction.

In: Leukefeld, C.G., and Tims, F.M., eds. Compulsory Treatment of Drug

Abuse: Research and Clinical Practice. National Institute on Drug Abuse

Research Monograph 86. DHHS Pub. No. (ADM)88-1578. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 8-34.

Chaiken, M.R. In-Prison Programs for Drug-Involved Offenders. Washington,

DC: U.S. Department of Justice, National Institute of Justice, 1989. 87 pp.

Collins, J.J., and Allison, M. Legal coercion and retention in drug abuse

treatment. Hosp Commun Psychiatry 34(12):1145-1149, 1983.

Frohling, R. Promising Approaches to Drug Treatment in Correctional Settings.

National Conference of State Legislatures. Criminal Justice Paper #7.

Washington, DC: U.S. Department of Justice, Bureau of Justice Assistance,

1989. 9 pp.

48
Hawkins, J.D.; Catalano, R.F.; and Wells, E.A. Measuring effects of a skills

training intervention for drug abusers. J Consult Clin Psychol 54(5):661-664,

1986.

Hubbard, R.L.; Collins, J.J.; Rachal, J.V.; and Cavanaugh, E.R. The criminal

justice client in drug abuse treatment. In: Leukefeld, C.G., and Tims, F.M,

eds. Compulsory Treatment of Drug Abuse: Research and Clinical Practice.

National Institute on Drug Abuse Research Monograph 86. DHHS Pub. No.

(ADM)88-1578. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988. pp. 57-80.

Maddux, J.F. Clinical experience with civil commitment. In: Leukefeld, C.G.,

and Tims, F.M., eds. Compulsory Treatment of Drug Abuse: Research and

Clinical Practice. National Institute on Drug Abuse Research Monograph 86.

DHHS Pub. No. (ADM)88-1578. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1988. pp. 35-56.

Simpson, D.D., and Marsh, K.L. Relapse and recovery among opioid addicts

12 years after treatment. In: Tims, F.M., and Leukefeld, C.G., eds. Relapse

and Recovery in Drug Abuse. National Institute on Drug Abuse Research

Monograph 72. DHHS Pub. No. (ADM)88-1473. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1988. pp. 86-103.

U.S. Department of Justice, Bureau of Justice Statistics. Report to the Nation

on Crime and Justice. 2d ed. Washington, DC, 1988.

U.S. Department of Justice, National Institute of Justice. Drug Use Forecasting:

January to March 7989. Washington, DC, 1989.

U.S. Department of Justice, Office of Justice Programs, Bureau of Justice

Assistance. Wisconsin’s Drug Abuse Treatment Unit. Bureau of Justice

Assistance monograph. Washington, DC, 1990.

Wexler, H.K.; Falkin, G.P.; and Lipton, D.S. Outcome evaluation of a prison

therapeutic community for substance abuse treatment. Crim Just Behav

17(1):71-92, 1990.

Wexler, H.K.; Lipton, D.S.; and Johnson, B.D. A Criminal Justice System

Strategy for Treating Cocaine-Heroin Abusing Offenders in Custody.

Washington, DC: U.S. Department of Justice, National Institute of Justice,

1988.

ACKNOWLEDGMENTS

Preparation of this manuscript was supported by U.S. Department of Justice,

Bureau of Justice Assistance, grant 87-DD-CX-0005.

The authors acknowledge the assistance of William Kearns, Ph.D., in

compiling and analyzing evaluation data from the drug treatment program

survey and from the model demonstration project in Tampa, FL. Assistance

also was provided by Peggy Glider, Ph.D., who compiled evaluation data

49
from the model demonstration project in Tucson, AZ. Drug treatment program

survey results also are described in “A Report of the Findings of a Survey of the

Nation’s Jails Regarding Jail Drug Treatment Programs” (May, B.; Peters, R.;

and Kearns, B., 1990), printed by the American Jail Association, Hagerstown,

MD, May 1990.

AUTHORS

Roger H. Peters, Ph.D.

Assistant Professor

Florida Mental Health Institute

Department of Law and Mental Health

University of South Florida

Tampa, FL 33612-3899

Robert May II, B.S.

Project Manager

American Jail Association

1000 Day Road, Suite 100

Hagerstown, MD 21740

50
HIV-1 Infection in the Correctional

Setting

David Vlahov

INTRODUCTION

Infection with human immunodeficiency virus type 1 (HIV-1), the cause of

acquired immunodeficiency syndrome (AIDS), is a major public health problem

in prisons and jails. Through October 1989, 5,411 cases of AIDS had been

reported from prisons and jails throughout the United States (Hammett 1990).

In several correctional systems, AIDS has become the leading cause of death

(New York State Commission of Corrections 1986; Salive et al. 1990a; CDC

Weekly 1989). The occurrence of AIDS in prisons and jails has stimulated

multiple serosurveys to identify the magnitude and scope of HIV-1 infection.

From the large number of HIV-1 seroprevalence surveys that have been

conducted in the United States, as reported elsewhere (Hammett 1990;

Centers for Disease Control 1987, 1989a), several trends can be identified.

In the United States and Europe, HIV-1 seroprevalence vanes considerably

by geographic region. U.S. seroprevalence rates have been lowest among

entrants to prisons in the Midwest region, with none in Idaho, 0.1 percent in

South Dakota, 0.2 percent in Nebraska, 0.3 percent in Wisconsin, 0.4 percent

in Oklahoma, 0.4 percent in Missouri, 0.4 percent in Iowa, and 0.8 percent in

Colorado. Conversely, rates have been highest in the mid-Atlantic States, with

17.4 percent in New York and 7.0 percent in Maryland (Hammett 1990; Truman

et al. 1988). In Europe, rates among prisoners ranged from none in Cyprus to

16.8 percent in Italy (Harding 1987).

Prevalence of HIV-1 infection in the correctional setting tends to exceed

prevalence in the general population. For example, the l-percent prevalence

of HIV-1 antibody among entrants to a military maximum-security prison (Kelley

et al. 1986) contrasts with the 0.15-percent prevalence among applicants to

U.S. military service (Burke et al. 1987). Although these two groups are not

strictly comparable because the samples were drawn at separate times in the

subjects’ respective military careers, these data highlight the need to focus

attention on HIV-1 in the correctional setting.

51
Despite geographical variation in HIV-1 seroprevalence among correctional

facilities, similarities have been noted across systems. The National Institute of

Justice (NIJ) recently supported an HIV-1 seroprevalence survey of male and

female entrants to 10 correctional systems within the continental United States

(Vlahov et al. 1991). The results from this study indicated geographic variation

but noted that HIV-1 seroprevalence was significantly higher among females

compared to males, among racial/ethnic minorities compared to whites, and

among inmates over 25 years of age compared to inmates under 25 years of

age. A comparison of two pairs of jails and prisons located in the same State

identified a similar HIV-1 prevalence among females and males, suggesting no

important difference between jails vs. prisons after accounting for geographic

variation.

The major risk factor for HIV-1 infection and AIDS in the correctional setting is

intravenous (IV) drug use prior to incarceration. Within the New York State

prison system, which conducts risk factor investigations on diagnosed cases of

AIDS, approximately 95 percent of inmates with AIDS reported a history of IV

drug use in comparison with 3 percent who acquired AIDS by homosexual

contact and were not IV drug users (Bureau of Communicable Disease Control

1989). Among 1,488 male entrants to the Maryland Division of Corrections

between April and June 1987, 7 percent were HIV-1 seropositive; 85 percent

of the seropositives were identified as IV drug users by history or observation

of needle tracks (Vlahov et al. 1989). Although IV drug use and homosexual

activity are acknowledged as continuing among a nontrivial proportion of

inmates (Decker et al. 1984; Nacci and Kane 1982), intraprison transmission

of HIV-1 has been found infrequently (Brewer et al. 1988; Kelley et al. 1986;

Horsburgh et al. 1990). This infrequent transmission of HIV-1 supports the

conclusion that IV drug use prior to incarceration is the predominant risk factor

for HIV-1 infection and AIDS among incarcerated populations.

The ability to project temporal trends of HIV-1 infection in the correctional

setting is of obvious value to correctional administrators, but its value has been

limited because most published serosurveys typically report prevalence for a

single year. Given that preincarceration IV drug use is the major risk factor for

HIV-1 infection in the correctional setting, early reports of temporal trends of

HIV-1 infection among nonincarcerated IV drug users raised concerns that the

prevalence of HIV-1 infection might increase dramatically. In particular, these

reports noted that once HIV-1 entered a community of IV drug users in New

York City, Milan (Italy), and Edinburgh (Scotland), dramatic increases in HIV-1

seroprevalence in the IV drug user population were observed within 2 to 4 years

(Novick et al. 1985; Angarano et al. 1986; Robertson et al. 1986). However,

other reports of nonincarcerated IV drug users noted a subsequent stabilization

of HIV-1 seroprevalence in IV drug user populations (Des Jarlais et al. 1989;

Moss et al. 1988; Brown et al. 1988; Peterson et al. 1988).

52
With respect to incarcerated populations, HIV-1 data are limited. In the

Maryland State prisons, data obtained over 3 years (1985 to 1987) showed

stable prevalence among males entering prison; this stability persisted in

multivariate analyses (Vlahov et al. 1989). Additional data for 1988 were

analysed and showed persistence of stability for HIV-1 antibody among male

entrants to Maryland State prisons (Vlahov et al. 1990). Similarly, stable

prevalence has been observed in a 1-year period in two other correctional

systems (Prendergast et al. 1989; Davis et al. 1989). Failure to detect an

increase in HIV-1 seroprevalence may be due to a variety of factors that

have been discussed in detail elsewhere (Vlahov et al. 1989; Des Jarlais et al.

1989). Briefly, these include random variation in sampling; an effect of active

risk reduction in response to the AIDS epidemic; and achievement of an

equilibrium among three variables: (1) the influx of uninfected individuals, (2)

the incidence of new infection, and (3) the exit of infected individuals through

death and migration. The extent to which these and possibly other factors

may help produce stabilization of prevalence among inmates entering prison

requires further investigation. Although these data may be reassuring to

correctional and public health officials, ongoing surveillance is prudent.

lntraprison transmission is related to the temporal trends of HIV-1 infection

in the correctional setting. Since homosexual activity and IV drug use are

acknowledged to occur in prison (Nacci and Kane 1982; Decker et al. 1984)

and the median length of incarceration is usually 2 to 3 years, concern exists

over the potential for correctional facilities to serve as an amplifying reservoir

of HIV-1 infection into the surrounding community. Transmitting HIV-1 during

incarceration was suggested by a Maryland Division of Corrections study

(Vlahov and Polk 1988). This study involved approaching 338 inmates who

had been incarcerated for at least 7 years prior to 1985. Of the 137 volunteers

in the study who were tested, the two found to be seropositive had each been

incarcerated for 9 years, and the estimated infection rate was 2.1 per 1,000

prison-years. Although no baseline specimens were available, the extended

duration of incarceration suggests that infection probably was acquired in

prison. Because the response rate was low and restricted to long-term inmates,

bias cannot be excluded. Subsequently, at a military maximum-security prison

that reported an HIV-1 seroprevalence of 1 percent at baseline, serologic

followup was performed on 567 inmates for whom negative baseline specimens

were available, and no seroconversions were identified (Kelley et al. 1986). In

the Nevada State prisons, which reported a baseline prevalence of 2.4 percent,

the intraprison transmission rate was calculated as 1.7 per 1,000 prison-years

(Horsburgh et al. 1990). In Maryland, which reported a baseline prevalence of

7.0 percent, the intraprison transmission rate was calculated as 4.2 per 1,000

prison-years (Brewer et al. 1988). Although these study samples included only

those inmates who were still incarcerated at the time of followup, the data

53
suggest that the risk of intraprison transmission is low. This documentation of

infrequent transmission and the observation of an apparent direct relationship

between HIV-1 seroprevalence at intake and risk of transmission (table 1)

suggest that, for most correctional facilities in the United States, intraprison

transmission is likely to be rare.

TABLE 1. Point estimates for prevalence and incidence of HIV-1

seropositivity among prison inmates, United States

Prison System

Prevalence on Entry Incidence per

(Percent) 1,000 Prison-Years

Military maximum security 1.0 0

Nevada 2.4 1.7

Maryland 7.0 4.2

To summarize, although available data on the geographical variation and

temporal stability in seroprevalence in combination with data suggesting

infrequent intraprison transmission appear reassuring, HIV-1 infection remains

a major prison health problem. Large numbers of persons either at risk for

infection or already infected continue to enter correctional facilities. However,

prudent policies are needed to continue monitoring, treating, and intervening

with this population and, thus, to efficiently prevent and control HIV-1 infection

in the correctional setting.

RESPONSE TO HIV-1 IN THE CORRECTIONAL SETTING

Responses to HIV-1 infection in the correctional setting have included inmate

risk education; screening for antibody to HIV-1 infection and segregation of

seropositive inmates; and, to a lesser extent, treatment for drug abuse.

Options and constraints for each of these approaches are discussed below.

Inmate Risk Education

In the third annual NIJ survey of U.S. correctional facilities, virtually all

jurisdictions reported offering or developing some AIDS training or educational

material for staff (97 percent) and inmates (96 percent) (Hammett 1990).

Despite this near universal application of education about risks, sparse data

are available on the preexisting level of knowledge about HIV/AIDS among

incoming inmates. Recently, Celentano and coworkers (1990) administered the

54
AIDS Awareness Questionnaire—developed by the National Center for Health

Statistics (NCHS) and given periodically to a random sample of the U.S.

population-to a sample of 210 consecutive male entrants to the Maryland

State prison system. These investigators reported that, within this sample,

knowledge about HIV/AIDS and the established routes of transmission and

prevention of transmission was high before receiving in-service education.

These results were similar to a random sample of U.S. males interviewed

during the same calendar period, with more than 95 percent correctly

responding that HIV was transmitted by sexual intercourse and sharing needles.

However, knowledge about casual contact transmission was lower, with 57

percent incorrectly reporting that HIV is transmitted by sharing eating utensils

with someone who has AIDS. The findings led Celentano and coworkers

(1990) to conclude that knowledge about established routes of transmission

and prevention of HIV-1 probably had been disseminated adequately prior to

incarceration but that clarification of unlikely transmission sources would seem

prudent.

More recently, Zimmerman and colleagues (1991) surveyed HIV-1 knowledge

and perceptions among 108 inmates from a Pennsylvania prison who

volunteered to participate. The same NCHS AIDS Awareness Questionnaire

was used. Their findings were similar with respect to knowledge, but they

noted a strong inverse association between knowledge about unlikely routes

of transmission and perception of risk while in prison. This inverse association

suggests that faulty knowledge about unlikely routes of transmission (e.g.,

through casual contact) might lead to a high perception of risk for acquiring

infection while in prison. Although the extent to which perception of risk as

associated with fear and concern was not measured, studies that have

identified intraprison transmission as infrequent (Brewer et al. 1988; Kelley et

al. 1986; Horsburgh et al. 1990) suggest that the risk perceptions reported by

these inmates may be unnecessarily high. These findings combined with

the data from Celentano and coworkers (1990) suggest that education

programs in the correctional setting should focus on clarifying unlikely routes

of transmission. Zimmerman and colleagues (1991) further noted that, among

the inmates surveyed, the most trusted sources of AIDS information were

television, newspapers, and the Division of Corrections’ programs and the least

trusted sources were correctional officers and other inmates. These findings

suggest strategies for focusing attention on educational interventions.

In summary, cost-effective planning for AIDS education programs should

recognize that fundamental concepts of HIV-1 transmission and prevention are

likely already to have been disseminated to inmates. A current focus for such

programs should include clarification of unlikely transmission sources, with the

objective of minimizing unnecessary fears and concerns.

55
In addition to clarifying concerns that arise during incarceration, HIV/AIDS

education in correctional settings has been discussed as having a second

objective. Prisons provide a high concentration of IV drug users. Surveys

have reported preincarceration drug use among 27 to 41 percent of prison

inmates (Anda et al. 1985; Decker et al. 1984; Hull et al. 1985; Vlahov et al.

1989). Also, samples of incoming inmates to a regional prison system involve

many IV drug users from a wide geographic area (e.g., approximately 1,500 IV

drug users per year in the Maryland Division of Corrections enter through a

single facility), and similar numbers are released each year. This access to

large numbers of IV drug users, many of whom have no history of drug abuse

treatment (Barton 1980) suggests an opportunity to reach efficiently an

otherwise difficult-to-access population. However, a recent survey of 1,580

active drug users in Baltimore, recruited through extensive community outreach

techniques, indicated that information about AIDS had been disseminated

adequately (Celentano et al. 1991). Therefore, education programs confined

to fundamental concepts about HIV transmission and prevention are likely to

be redundant. Although the correctional setting provides a unique opportunity

to efficiently reach many IV drug users, the most cost-effective approach to

facilitate desired behavioral change requires further work.

Serological Screening of Inmates

As a discrete public health policy, much discussion has surrounded the issue

of screening inmates for antibody to HIV-1 and segregation of seropositives.

In a survey of U.S. correctional systems in 1987 and 1988, Hammett (1990)

summarized the position of proponents and opponents. Briefly, proponents

argued that screening would permit identification of infected individuals and

segregation would permit closer monitoring of infected individuals to reduce

risk of transmission and to initiate treatment for complications of HIV-1 infection.

Opponents argued that, for most correctional systems, the risk of HIV-1

transmission was low, so that mass screening was not cost-effective. In

addition, opponents argued that treatment of HIV-1 for asymptomatics was not

available. With the multitude of logistical problems surrounding mass screening

and segregation in the correctional setting, it was argued that such basic issues

as confidentiality of test results and the potential for positive test results to lead

to inmate victimization had not been addressed adequately.

More recently, recommendations and guidelines for the early treatment

of HIV-1 infection have been published (Centers for Disease Control 1989b;

Salive et al. 1990b; Volberding et al. 1990). These guidelines call for identifying

HIV-1 infection and monitoring immune parameters to start chemotherapy in

asymptomatic individuals, with the goal of delaying onset of HIV-1 related

disease.

56
With the advent of multiple chemotherapeutic protocols for asymptomatic

HIV-1 infected individuals, the issue of serological inmate screening shifts

dramatically. Rather than debating the merits of mass screening, the

issue now shifts toward defining efficient and cost-effective identification

of HIV-1 seropositive inmates with adequate safeguards for protecting

their confidentiality. Cost estimates for implementing recommendations

to perform serological screening with appropriate confirmatory testing,

measuring immune parameters on a semiannual basis for HIV-1 infected

individuals, and administering chemotherapy are beyond the scope of this

discussion. However, crude calculations suggest that many prison systems

might need to consider supplemental budgets of hundreds of thousands of

dollars per year.

Two factors can be considered as potentially offsetting the costs of

implementing the recent recommendations for treating HIV-1 infection.

First, careful attention to ethical and confidentiality considerations suggest

that voluntary rather than mandatory serological screening may be the

preferred approach. The proportion of inmates who might volunteer for

screening is difficult to predict, but it would probably be lower than the prison

population because of inmate concerns about maintaining confidentiality

of test results in the correctional setting. Nevertheless, prior to publishing

treatment recommendations for asymptomatically HIV-1 infected individuals

(Centers for Disease Control 1989b), data from Wisconsin prisons indicated

that 71 percent of inmates volunteered for confidential HIV-1 testing (Davis

et al. 1989). If treatment protocols were available, an increase in participation

is conceivable. Based on these limited data, the economic impact of

nonparticipation in voluntary testing on budget projections for a comprehensive

HIV-1 screening and treatment program probably should be estimated as

minimal.

A second factor that potentially may offset costs for implementing a

comprehensive HIV-1 screening and treatment program is the ability to

identify and target subgroups most likely to benefit from intervention.

Although several studies have been published that identify IV drug users,

minorities, women, and those older than 25 as significant independent risk

factors for being HIV-1 infected upon entry into prison (Vlahov et al. 1989,

1990; Truman et al. 1988), more research is needed to refine categories and

examine generalizability. These data also require detailed discussion by

correctional and public health officials to weigh their policy implications for

targeting interventions.

57
Treatment for Drug Abuse

Another HIV-1 related intervention to promote in correctional settings is drug

abuse treatment. Large numbers of IV drug users, a major risk group for HIV-1

infection, are found in the correctional setting and a substantial proportion report

no history of drug abuse treatment (Barton 1980). Facilitating abstinence

through treatment is important to prevent acquisition of HIV-1 infection.

Treatment also may be important for HIV-1 infected drug users because of

an observed inverse association between rate of decline in CD4 cell levels

by frequency of continued injections (Des Jarlais et al. 1987). This inverse

allocation suggests that abstinence may slow progression to clinical disease.

Although another group of investigators (Schoenbaum et al. 1989) did not

replicate this finding, promoting abstinence among HIV-1 seropositive IV drug

users is likely to reduce the possible reservoir for parenteral transmission.

SUMMARY

The correctional setting provides an opportunity to serve IV drug users who

might otherwise be difficult to access. Interventions-including education,

counseling, treatment for HIV-1 infection, and treatment for drug abuse—

conducted in the correctional setting could have benefits for individual inmates

and the surrounding community.

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Peterson, L.R.; Cartter, M.; D’Aquila, R.; and Williams, A. “HIV Seroprevalence

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Peutherer, J.F.; and Brettle, R.P. Epidemic of AIDS related virus (HTLV-III/

LAV) infection among intravenous drug users. Br Med J 292:527-529, 1986.

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human immunodeficiency virus type 1 (HIV-1) in male prison inmates. Public

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60
Infection and Diseases.” Paper presented at the 5th International

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Truman, B.I.; Morse, D.; Mikl, J.; Lehman, S.; Forte, A.; Broaddus, R.; and

Stevens, R. “HIV Seroprevalence and Risk Factors Among Prison Inmates

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and Muñoz, A. Prevalence of antibody to HIV-1 among entrants to U.S.

correctional facilities. JAMA 265:1129-1132, 1991.

Vlahov, D.; Brewer, F.; Muñoz, A.; Hall, D.; Taylor, E.; and Polk, B.F. Temporal

trends of human immunodeficiency virus type 1 (HIV-1) infection among

inmates entering a statewide prison system 1985-1987. J Acquir Immune

Defic Syndr 2:283-290, 1989.

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Seasonal and annual variation of antibody to the human immunodeficiency

virus type 1 (HIV-1) among male inmates entering Maryland prisons:

Update. AIDS 4:345-350), 1990.

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virus (HIV) infection in prison. AIDS Public Policy J 3(2):42-46, 1988.

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P.A.; and Balfour, H.H. Zidovudine in asymptomatic human

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ACKNOWLEDGMENT

The work described in this chapter was supported by National Institute on

Drug Abuse grants DA-04323, DA-04334, and DA-05664 and by NIJ grant

88-IJ-CX-0010.

AUTHOR

David Vlahov, Ph.D.

Assistant Professor of Epidemiology

The Johns Hopkins University School of Hygiene and Public Health

Room 897

624 North Broadway

Baltimore, MD 21205

61
Drug Abuse Treatment Programs in the

Federal Bureau of Prisons: Initiatives

for the 1990s

Donald W. Murray, Jr.

INTRODUCTION

Interest in providing quality drug abuse treatment programs to incarcerated

Federal offenders within the Federal Bureau of Prisons (BOP) is not a recent

development. BOP has, in fact, provided treatment services to offenders with

significant drug abuse problems over the past quarter century (Wallace et al.

1990). Although program offerings within the agency generally have been

consistent with the broader social views regarding treatment and rehabilitation

as a function of prisons (Wallace et al., in press), the agency historically has

perceived opportunities for treatment of drug-abusing or addicted offenders as

an important part of its mission.

Not unlike most State correctional systems, BOP has experienced a rapid

and dramatic increase in population. Currently, there are approximately

56,500 individuals incarcerated in more than 60 facilities throughout the

country. Nearly 50 percent of all offenders are serving time for a drug-related

offense. It is projected that the total offender population will reach 95,000 by

1995, and nearly 69 percent will be incarcerated for drug offenses-more than

the total current BOP population (Federal Bureau of Prisons 1989).

Although the exact percentage of individuals with drug abuse problems who are

serving time for a drug-related offense is unknown, it is known that a significant

number have substantial drug problems and histories. In addition, significant

numbers of individuals commit crimes that are not specifically drug offenses

under Federal law but may be motivated by drug use. More precise data in

these areas, as well as type and duration of substance abuse, motivation for

treatment, and selected demographic characteristics, await the outcome of the

Comprehensive Substance Abuse Assessment Project (Whittenberger, in

press).

62
Available data suggest that approximately 46 percent of all incarcerated

Federal offenders have moderate to severe drug abuse problems. About 47

percent of male offenders and 30 percent of female offenders report moderate

to severe substance abuse problems on admission to the system. This is

generally consistent with, yet somewhat lower than, the findings of several

State systems.

In 1986 the Bureau of Justice Statistics reported that 62 percent of State

inmates reported using illicit drugs on a regular basis, and 43 percent reported

drug use on a daily basis during the 30-day period prior to committing the

offense for which they were imprisoned (Innes 1988). Study data from some

jails in New York City are more ominous, indicating that up to 85 percent of

arrestees reported prior drug use on at least a weekly basis prior to arrest

(Coughlin 1989).

Chaiken (1989) has noted that more than 50 percent of all inmates in the

United States were using illegal drugs routinely prior to their last arrest but

were not receiving treatment while incarcerated. The lack of effective

treatment programs within the correctional setting and the reasons underlying

this unavailability have been noted by several authors, perhaps most articulately

by Gendreau and Ross (1987), Wexler and Williams (1985) and Van Voorhis

(1987).

Although some controversy remains regarding the manner in which drug abuse

may result in criminal behavior, recent longitudinal research findings indicate

that addiction serves as a “multiplier” of crime. Despite the fact that criminal

behavior frequently occurs prior to addictive behavior, addictive behavior leads

to greater criminal behavior (Nurco et al. 1985). Clearly, the need exists to

develop new program efforts in correctional settings. As numerous studies

have demonstrated, treatment is effective in reducing posttreatment drug use

(Tims 1984; Tims and Ludford 1984; Wexler et al. 1985; Simpson 1984;

Hubbard et al. 1984; Anglin and McGlothlin 1984; Bureau of Justice Assistance

1988) and reduces future criminal behavior following both prison-based and

community-based programs (De Leon 1985; Gendreau and Ross 1987; Anglin

and McGlothlin 1984; Simpson and Friend 1988).

The recent findings involving long-term outcome studies of offenders who

have received treatment while incarcerated are among the forces that have

placed renewed emphasis on providing drug-impaired individuals with

expanded treatment opportunities within BOP. In addition, as a part of an

overall National Drug Control Strategy (Office of National Drug Control

Strategy 1989, 1990) there has been increased emphasis on the serious

consequences of drug abuse for the country as a whole and its impact on

the criminal justice system specifically.

63
BOP provided additional impetus to enhanced treatment initiatives by

sponsoring a National Drug Treatment Issues Forum in Washington, DC,

in September 1988. The conference explored drug treatment strategies

for Federal offenders and the increase in awareness of treatment issues and

initiatives across the country. The conference was attended by researchers,

administrators, program staff, practitioners, and representatives from the

judiciary and legislature. Several recommendations resulted from the

conference, which have facilitated the development of current BOP

comprehensive strategy.

Before reviewing current treatment program developments, this chapter

gives a summary and overview of drug programs implemented over the

past 2 1/2 decades that will provide a perspective for BOP’s new strategy.

HISTORICAL REVIEW OF BOP DRUG PROGRAMS

BOP historically has provided drug treatment programs for inmates with

drug abuse problems. Since the mid-1960s BOP has offered drug treatment

programs based on individual needs. This commitment to treatment and

education has continued over the past 2 112 decades, consistent with

resources allocated to the agency. The following list reflects BOP’s efforts

toward treatment and education in a chronology of drug abuse treatment

programing from 1966 through 1989.

1966-71

—Narcotic Addict Rehabilitation Act (NARA).

—Established Public Health Service programs at several institutions (e.g.,

Ft. Worth, TX, and Lexington, KY).

—Research on NARA programs indicated they were “moderately”

successful and that some treatment is better than none.

1971-78

—BOP began establishing Drug Abuse Programs (DAPs) intended to

“expand” on the apparent success of NARA programs and reinforce

the development of “Functional Unit Management.”

—In 1978, 33 DAP units in 24 institutions (some institutions had one

program for alcoholics and another for “drug” abusers).

64
1978-84

—First Task Force on DAPs (credibility/accountability of Drug/Alcohol Unit

programs of concern).

—Drug Abuse lncare Manual published—26 recommendations; all

programs had to be “certified.”

—A brief (approximately 2 years) improvement in drug programing followed

publication of the lncare Manual. Beginning about 1980, a decline in

quality began (apparent deemphasis on certification process; erosion of

resources, etc.).

1984-86

—Second Task Force on DAPs.

—Insufficient data for evaluation of existing programs.

—40 to 50 percent of new inmate admissions with histories of drug abuse

in 1984.

—4,500 inmates in 22 programs.

—162 total positions (staff/inmate ratio of 6 per 170).

—Executive Staff recommended new program direction with “education

emphasis.”

1986-88

—National Chemical Abuse Program Statement mandated “low-intensity”

programs at all institutions.

—Standards written to enable all institutions to meet “minimum criteria.”

—Three unit-based (residential) programs remained at the end of 1987;

remainder centralized (inmates housed throughout the institution and

attended programs at a central location).

—Enrollment at the institution is voluntary and averages 3,000 per month.

65
—Higher quality programs at lower security levels.

—Work groups formed to consider the development of prerelease

community drug treatment programs.

1988-89

—Total DAP enrollment of about 1,800.

—Development of Comprehensive Drug Abuse Treatment Strategy for

Federal inmates.

—Establishment of a Central Office Coordinator of DAPs

—Approval by Executive Staff of three “high-intensity” research programs.

—Development of ongoing research and data collection component to add

to knowledge guide in decisionmaking and assist with quality control.

—Ongoing development of community-based drug treatment programs to

provide aftercare following release from the high-intensity programs.

1990

—-Refinement of Comprehensive Drug Abuse Treatment Strategy.

—Mandatory Drug Education Programs implemented throughout all BOP

facilities.

—Drug Abuse Counseling Programs (outpatient) put into effect in all BOP

facilities.

—Five Comprehensive Drug Abuse Treatment Program Unit sites selected

and funded.

—Three Pilot Research Program Units became fully operational.

—Transitional Services Programs enhanced for offenders completing

treatment.

—Drug Abuse Program Evaluation Strategy completed by Office of

Research and Evaluation.

66
—Agreement with National Institute on Drug Abuse (NIDA) to provide

funding for long-term outcome studies of program effectiveness.

—Program enrollment reaches 3,800 participants.

Prior to the enactment of NARA in 1966, selected Federal inmates with narcotic

abuse histories received assistance and supervision in one of two U.S. Public

Health Service hospitals located in Lexington, KY, and Fort Worth, TX. NARA

mandated in-prison drug treatment for narcotic addicts who were convicted of

violating Federal laws. It called for the creation of unit-based programs

(i.e., inmates assigned to live in specific housing units that were separate

from the general inmate population and were staffed by a team that included

treatment professionals) and for aftercare services (postrelease counseling

and urinalysis). The first such drug treatment unit was opened in March 1968

at the Federal institution in Danbury, CT. Additional NARA units opened during

1969 and 1970 at institutions in Terminal Island, CA, Alderson, WV, Milan, MI,

and LaTuna, TX.

These drug treatment units were based on the therapeutic community (TC)

model (a 24-hour learning environment using both peers and staff as role

models), with an emphasis on group therapy. All NARA participants were

required to participate in postrelease aftercare, which usually consisted of

frequent drug urinalyses and community-based counseling programs.

Evaluations (Breen et al. 1982; CONSAD Research Corporation 1974)

were conducted on the effectiveness of the NARA drug treatment programs

in decreasing criminal behavior and drug use among releasees. General

findings from the above studies indicated the following:

1.

2.

3.

4.

NARA graduates showed less frequent drug usage and involvement

in drug sales after release than comparison subjects.

NARA graduates showed lower recidivism rates (20 to 30 percent)

than inmates, matched for frequency of drug use prior to

incarceration, not placed in drug programs (65 percent).

Inmates who were more involved in the programs were more

successful in terms of decreased criminal behavior and drug use

after release.

Women who graduated from the NARA program tended to be more

successful on outcome measures than men who completed the

program.

67
5. Inmates felt that group and individual counseling was the most

helpful element of the treatment programs.

With the successful operation of NARA drug treatment units, it soon became

evident that there was a large population of inmates who could benefit from

such drug treatment programs but who were not sentenced under the restrictive

NARA statutes. For example, repeat offenders and inmates whose current

offense involved violence were excluded from NARA sentencing. Beginning

in July 1971, drug treatment units were opened to serve inmates with a

demonstrated need for drug treatment programing who were not sentenced

under NARA. By 1972 all these programs were authorized to provide aftercare

services for program participants. By 1978 there were 33 drug treatment units

in Federal institutions.

A typical drug treatment unit at that time housed 100 to 125 participants

and was staffed by one unit manager, one psychologist, one or two

caseworkers, and one or two correctional counselors. Outside consultants

(sometimes ex-addicts) and education staff also provided services to the

participants. Although the elements of these treatment programs were not

standardized, they generally included an orientation period, unit-based

programing (such as group therapy sessions and individual counseling),

eventual participation in institution programs (educational, vocational,

recreational), prerelease counseling, and postrelease aftercare.

By 1979 BOP required all drug treatment programs to meet the standards

applied to NARA programs with the authority to conduct NARA study

evaluations. Thus, NARA commitments could be designated to any institution,

rather than restricted to facilities with NARA programs. This resulted in the

decline of ‘NARA-only” drug units and the publication of the system-wide

Drug Abuse lncare Manual.

The Drug Abuse lncare Manual, a program statement released by BOP in July

1979, called for the establishment of unit-based drug treatment programs in all

institutions. It also specified minimum standards for certification of each drug

treatment program, staff qualifications, staff program involvement, treatment

phases, inmate certification for completion of program, aftercare arrangements,

and data collection for evaluation purposes.

Although the publication of the lncare Manual led to an improvement in

BOP’s drug treatment programs for several years, the quality of these

programs began to decline in the early to middle 1980s. Correspondingly,

drug treatment evaluation efforts during this period were less intensive than

during the early and middle 1970s. Evaluation techniques (e.g., controlling

68
for severity of addiction, motivation for selection, and quality of program

participation) were not built into the design of these programs, and researchers

had difficulty in retrospectively reconstructing the data required for evaluation

purposes. Thus, the possibility for a thorough evaluation of these programs

was restricted severely.

Because well-designed evaluations of program effectiveness were lacking, a

task force was assigned in 1985 to review BOP drug treatment programs.

The task force members concluded that the programs had begun to erode

due to diminished resources that were diverted for other high-priority purposes,

including the pressures of an increasing inmate population, a lack of centralized

leadership and coordination within BOP, and a shortage of qualified and

properly trained staff. As a result of these findings, a program statement was

issued in 1986 calling for the establishment of a chemical abuse program

coordinator in each institution. Each institution’s warden was to decide on the

type of program to be offered and the number of staff members to be devoted

to drug treatment efforts. Most institutions chose centralized programs. Thus,

inmates housed throughout the institution participated in program activities at

a central location. By 1987 only three unit-based drug treatment programs

remained in BOP.

Currently, and during 1987 through 1989, the majority of BOP substance

abuse programs are considered “low intensity,” with an emphasis on drug

education. The program techniques are varied. Approximately one-third of

the institutions have self-help groups such as Alcoholics Anonymous (AA)

and Narcotics Anonymous (NA). Other available programs include group

psychotherapy and training in communication skills, personal development,

values clarification, stress management, positive thinking, and assertiveness.

Some programs also offer individualized counseling, vocational planning, and

prerelease planning. Many group programs are of specific length, running

from 6 to 12 weeks. However, some institutions, such as Federal Correctional

Institution (FCI) Tallahassee and FCI Fort Worth, offer multistage programing,

allowing inmate participation over a longer period. With the greater influx

of Hispanic inmates, a few initiatives have been taken to provide programs

for inmates who are not fluent in English. FCI Fort Worth provides

a 12-week program led by Spanish-speaking staff and an AA group led by

a Hispanic volunteer.

In BOP, inmates generally enroll in drug treatment programs at the beginning

of their incarceration. During their orientation to the institution, new inmates

receive information about available programs. In addition to self-referral,

inmates often are recommended for program participation by their unit team

during their initial classification. Although program enrollment is voluntary,

69
priority is given to inmates with court orders to receive treatment as well as to

inmates with severe substance abuse problems. Recent monthly participation

rates show that nearly 3,800 inmates, or about 7 percent of the total inmate

population, currently are enrolled in a substance abuse treatment or education

program.

In 1988 a national DAP coordinator position was established in Washington,

DC, to oversee the development and implementation of the new drug treatment

strategies for Federal inmates. In addition to continuing but enhancing the

established low-intensity drug treatment programs, plans are well under way for

revising drug education programs and for developing new unit-based intensive

drug treatment programs.

NEW DRUG ABUSE TREATMENT STRATEGY INITIATIVES

The comprehensive drug abuse treatment strategy for BOP calls for the

development of a layered, multitiered approach to programing. There is one

level for the delivery of drug education services, three treatment levels, and

one level of transitional services. They are as follows:

1. Drug Education Programs

2. Drug Abuse Counseling Services (outpatient)

3. Comprehensive DAPs (residential)

4. Pilot DAPs (residential/research)

5. Transitional Services (aftercare/community reentry)

A comparison of the elements of these five program types is provided in table 1.

Drug Education Programs

The Drug Education Program will be mandatory for inmates with a substance

abuse history who meet the following criteria: (1) all inmates for whom there

is evidence in the presentence investigation that alcohol or other drug abuse

contributed to the commission of the current offense, (2) individuals whose

alcohol or other drug abuse was a reason for a violation of parole or probation

supervision for which the subject is now incarcerated, and (3) inmates for whom

there is a court recommendation for drug programing. The program also will be

available to volunteers; however, priority will be given to inmates with alcohol

and other drug abuse histories.

Drug abuse treatment specialists will be employed under the supervision of the

Psychology Department in all facilities. Students will be required to complete a

standardized course during their first 6 months of incarceration. The criteria for

70
TABLE 1.

Program

Characteristics

Duration 4-10 hr/wk

until

completion

Hours

required

Staff/inmate

ratio

4 0

N/A

Participants Required ii

drug/crime

history;

volunteers

Point in

incarceration

First 6 months

Completion Attendance.

criteria pass test

Urinalysis same as

inmates in

general

population

Comparative analysis of BOP’s drug education and treatment

programs—1990

Drug

Education

Programs

Drug Abuse

Counseling

Services

Continuously

available

Variable

Variable

Volunteers

Anytime during

incarceration

Attendance

Same as

inmates in

general

population

Comprehensive

DAPs

Pilot

DAPs

Transitional

Services

9 months plus

supervised

aftercare

500

1:24

Volunteers

Preference to

those inmates

15-24 months

prior lo release

Attendance,

review by

treatment staff

More often

than inmates

in general

population

12 months

plus supervised

aftercare

1,000

1:12

Randomly

assigned

volunteers

Preference to

those inmates

15-24 months

prior lo release

Attendance,

review by

treatment staff

More often

than inmates

in general

population

6 months CCC

plus 6 months

supervision

Variable

To be

determined

Inmates who

have completed

a drug program

CCC placement

and postrelease

To be

determined

Variable,

more often in

early months

of CCC

placement

KEY: CCC=community correction center

program completion include class attendance and a passing score on an

objective standardized written test. As an incentive to stay in the program,

inmates who are required to complete the program but fail to do so will be

restricted to the lowest inmate pay grade. In addition, they will be ineligible for

halfway house placement and other community activities that are available to

carefully screened individuals during the latter portions of their sentences.

The primary objectives of the course are (1) to promote an understanding as to

how and why individuals abuse substances or become addicted, (2) to facilitate

understanding of the effects that continued abuse can have on one’s health and

life, (3) to assist the student in understanding the difficulties in the treatment of

71
abuse, (4) to demonstrate that treatment can be successful, (5) to convey the

understanding that programs are available to individuals while incarcerated and

in the community, and (6) to develop a sense of trust and cohesion in small

group settings, which motivates a desire for further treatment for those who

need it.

Specific content of the course includes chapters on the following topics:

Overview of Drug Education Program

Models of addiction

Explaining addiction

A general overview of drugs and drug terminology

Alcohol and other sedatives

Narcotics

Cocaine (and crack)

Stimulants other than cocaine

Tobacco

Hallucinogens

Cannabis (marijuana)

Human immunodeficiency virus infection and acquired immunodeficiency

syndrome

The impact of alcohol and other drug abuse on the family

Relapse prevention

The text and materials were prepared by psychologists within BOP. Small

groups will undergo the course 4 to 10 hours per week, at the institution’s

prerogative, until it is completed. Students who do not meet the mandatory

criteria for successful completion will be given specific feedback regarding

deficit areas and given an opportunity to remediate. A minimum score of 70-

percent mastery on field-tested exams, with specific norms and valid items,

is required to complete the course successfully.

72
Roth English and Spanish versions of the course will be available, and all

exemptions by reason of cognitive impairment or other disabilities will be

provided by a mental health professional. A standardized Certificate of

Completion will be awarded to all who successfully complete the course.

Drug Abuse Counseling Services

Centralized outpatient drug abuse counseling services will be available to

volunteers at all institutions at any time during their incarceration. (Outpatients

in a prison setting are inmates who participate in day-to-day activities with

other inmates and receive treatment services by appointment.) These

services will include individual counseling with a drug abuse treatment

specialist or a psychologist, group therapy sessions on drug-related topics,

self-help groups such as AA and NA, stress management and personal

development training, vocational training, and prerelease planning. Some

programs will have specific lengths and completion criteria, whereas others

will allow inmates to participate in ongoing therapy.

All individuals enrolled on an outpatient basis will have a treatment plan for

the specific group or individual sessions in which they are involved, with the

exception of self-help groups. These programs may be recommended,

however, as a part of the individual’s treatment needs, and participation will

be monitored by the treatment staff. The frequency and duration of each

inmate’s participation in outpatient counseling services will be tracked using

BOP’s computerized Psychological Information Management System.

The Drug Abuse Counseling Program is intended to provide maximum flexibility

to the needs of the offender, particularly those individuals who have a relatively

minor or low-level substance abuse impairment. Such offenders do not require

the intensive levels of treatment needed by individuals with moderate-to-severe

addictive behavioral problems.

A second purpose of the program is to provide those offenders who do

have moderate to severe drug abuse problems with supportive program

opportunities during the time they are waiting to participate in the highly

structured Comprehensive Residential Drug Treatment Units. As discussed

in the next section, individuals are not permitted to participate in the residential

program units until they are within 15 to 24 months of release.

The reasons for this are threefold: First, the limitations on available resources

preclude the development of sufficient numbers of units to meet the needs of

the total drug-abusing population, many of whom are serving quite extended

sentences as a result of the Comprehensive Crime Control Act of 1994 and

73
other criminal statutes enacted by the 98th Congress. Second, there is also

the question of treatment motivation for many such individuals. Data from the

Substance Abuse Assessment Project, which was conducted within BOP

during June and July 1990, should assist in refining knowledge in this area

and facilitate program planning. Third, some research suggests that

individuals who participate in a prison-based TC for longer than a year

do not have outcomes that are as successful as those who participated for

9 to 12 months and then are discharged from the program to the community.

Wexler and colleagues (1985) found that individuals who participated in a

prison-based TC for longer than 12 months, due to negative Parole Board

decisions, had poorer outcomes than those who were discharged to the

community after participating between 9 and 12 months in the TC. Hence,

an intensive residential treatment period of between 9 and 12 months near the

end of an offender’s sentence, coupled with an individually tailored community

transitional services program, may provide the best clinical outcomes and

optimal resource utilization. Caution must be exercised with this interpretation,

however, as factors such as length of treatment and timing of the intervention

with prison populations have yet to be more fully investigated.

Comprehensive Residential Drug Abuse Treatment Programs

Comprehensive Residential Drug Treatment Units will be developed throughout

BOP. Currently, five units have been approved with staffing and funding

allocations. These five units were operational by January 1, 1991. Additional

units are planned for 1991 and 1992. Each unit is capable of handling between

100 and 125 offenders during a 9-month program. Planning for the projected

growth in the population of substance-abusing offenders is ongoing.

Comprehensive residential treatment programs accept volunteers only.

Inmates apply for admission through their case managers who will determine

if the following criteria are met:

Between 18 and 24 months remaining to serve until release date

No detainers, pending charges, State commitment obligations, or

negative behaviors that could interfere with placement in a prerelease

or aftercare program

No history of violence/assaultive behavior

Fluency in English

74
No serious medical problems or other limitations that would prevent

program participation

Not a State boarder

Inmates meeting these basic criteria then will be referred to an institution

psychologist for assessment of drug abuse problems through a self-report

survey, Inventory of Substance Use Patterns (ISUP) (Whittenberger 1991),

and a record review. Inmates with a moderate-to-severe substance abuse

problem (DSM-III-R) who meet the above criteria will be considered eligible

for program assignment.

All Comprehensive Residential Drug Treatment Units will include the following

components:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Unit-based programs

Treatment staff-to-inmate ratio of 1:24

Program participation of 9 months and 500 program hours minimum

Individualized treatment plans based on comprehensive assessment

A prerequisite of 40 hours of drug education

Approximately 3 hours of drug treatment programing per day

Comprehensive assessment, 40 hours

Core group/individual treatment, 280 hours

Wellness lifestyle training, 100 hours

Transitional living issues, 40 hours

Full team reviews every 90 days

Treatment reviews every 30 days

Increased frequency of random urinalysis surveillance

Preference to inmates who are within 15 to 24 months of release

Comprehensive transitional services

Group and individual treatment focuses on a variety of skills development

issues, both cognitive and behavioral in nature. Criminal thinking confrontation

and prosocial values development are included whenever indicated. Family

issues, vocational/educational issues, relapse prevention, self-help, personal

development, and support groups are a routine part of the individual’s program.

The focus on the individual hopefully will assist in avoiding a “uniformity

myth” (Donovan 1988)—that all addictions are the same, common to many

traditional programs, both in prison and in the community. Indeed, there are

marked differences among substance abusers in age, gender, socioeconomic

background, family and social support resources, culture, ethnicity, personality,

cognitive functioning, attributional styles, belief systems, and medical conditions.

75
It is the heterogeneity of the substance-abusing population, rather than its

uniformity, which is of increasing interest in the community (Lawson and

Lawson 1989) and in prison settings (National Institute of Corrections 1991).

As such, it seems only prudent that DAPs incorporate comprehensive

assessments in these areas for individualized treatment plans. This is not to

say, however, that many drug-impaired individuals do not have common needs,

which can be met effectively in a group format. It seems, however, in reviewing

the history of treatment programs, particularly those in correctional settings, that

there is more interest in treating addictive behavior based on pharmacologic

classification (i.e., alcoholics, heroin addicts, cocaine or crack addicts) rather

than according to variables that have greater relationship to the development

and maintenance of the behavior. With this in mind, it seems unremarkable

that some previous programs and some contemporary ones achieve the low

to modest "success rates” that have been reported.

BOP’s comprehensive residential programs will be based on a

biopsychosocial model of substance abuse. Treatment will include a

strong relapse prevention emphasis. The goal of relapse prevention

treatment is to provide individuals with the behavioral and cognitive skills

necessary to cope effectively with high-risk situations (Marlatt and George

1984; Marlatt and Gordon 1980, 1985). Individuals are taught how to respond

to a lapse (i.e., a single incidence of return to drug use) and how to achieve

a positive lifestyle characterized by a balance between work and recreation

and by healthy habits, such as exercise, to reduce stress. It is in this latter

regard that a strong commitment to a rigorous wellness lifestyle schedule will

be maintained and integrated into the community. Indeed, daily wellness

program activities are expected of participants to help them modify their

abusive and addictive lifestyles. This will be an interesting area of future

research, comparing the relative effectiveness of programs with and without

wellness program components.

On successful program completion, the offender is prepared for release to

the community through a community treatment center facility, operated or

contracted by BOP. A tremendous amount of readiness preparation, however,

occurs during the last 3 months, particularly in the relapse prevention area.

High-risk situations are discussed, including family issues, job issues, and

supervision concerns. A specific relapse prevention plan is prepared for the

individual. Individuals also will have an opportunity to be gradually phased into

the community for up to a 6-month period, with support services provided by

BOP.

76
Pilot Drug Abuse Treatment Programs

By June 1990 three pilot drug abuse treatment units were partially operational

at FCls located in Butner, NC, Tallahassee, FL, and Lexington, KY. They

were fully functional by the end of 1990. These residential pilot programs have

a strong research emphasis and will involve larger investments of staff and

fiscal resources. They will remain pilot programs until an outcome evaluation

indicates whether the additional resources produce more positive postrelease

outcomes. Table 2 describes these three Pilot Drug Abuse Treatment

Programs for Federal offenders,

These pilot programs are very similar to the comprehensive programs with the

following exceptions:

1. Treatment staff-to-inmate ratios of 1:12

2. Program length of 12 months

3. 1,000 hours of treatment

4. Random assignment to program from a volunteer pool

5. Extended participation in outcome studies

Although most pilot and comprehensive programs are based on a

biopsychosocial model, there are some treatment differences among each

of the programs. The following are examples of these differences:

1.

2.

3.

4.

The programs at FCI Tallahassee and FCI Butner emphasize a social

learning philosophy, whereas the program at FCI Lexington uses the more

traditional AA or NA 12-step approach model.

The number of treatment hours per day differs between the FCI

Tallahassee and Butner programs (4 hours treatment, 4 hours work) and

the Lexington program (10.5 hours treatment).

FCI Tallahassee and FCI Lexington are both security-level-two institutions

and serve primarily security-level-two inmates. FCI Butner is an

administrative facility; thus, its program will serve inmates of all security

levels.

FCI Lexington serves female offenders only; FCI Butner and FCI

Tallahassee serve males only.

It is hoped that research will provide additional information regarding factors

related to treatment process and outcomes that will enhance future treatment

77
TABLE 2. Comparison of the three Pilot Drug Abuse Treatment Programs for

drug-involved Federal offenders

Site Location

Program Characteristics FCl Tallahassee FCl Butner FCI Lexington

Primary

approach of

program

Social learning treatment

philosophy with major

emphasis on relapse

prevention. Skills

training, attack on

criminal habits.

enhancement of positive

feelings. reduction of

negative feelings. TC

organization for inmates

before release and

during aftercare.

In-prison

program

activities

Type of program

setting

Hours inmates

are In program

area each day

Academic/vocatlonal/ Five program stages

UNICOR training: Group operating on a 4-month

and individual cycle with 21 subjects

counseling, wellness in each stage. Stage

program, special one includes evaluation/

seminars, general orientation. Stages two,

meetings. Up to 8 three, and four include

cohorts, with 12 or 13 components of

subjects in each cohort. education, relapse

Four hours of prevention, skills

introduction; 10 hours of training, wellness

preprogram assessment; training, academic/

4 hours of habrt vocational training,

modification; 32 hours of and personal

goal development; 68 counseling. Stage five

hours of reduction of is the prerelease phase

negative feelings; 82 focusing on

hours on motivations lo development of

change. aftercare plan.

Residential unit within a

security-level-two FCI,

including dormitories and

dayrooms. Staff offices

located within the unit.

Unit is not separate from

general population

inmates. Male inmates

only.

Residential unit within

an administrative FCI

housing all securitylevel inmates. Not

separate from general

population inmates

Treatment stall located

within unit. Male

inmates only.

4 hours treatment. 4

hours work

Development of

adaptive selfmanagement coping

skills leading to a

constructive lifestyle

free of drugs and crime.

rewarding leisure and

recreational activities,

constructive work

habits. and realistic

release plans conductive

to a successful drugfree community

adjustment.

4 hours treatment, 4

hours work

Traditional 12-step

model used in AA/NA

treatment. Addiction is

viewed as a disease

that leads to physical

deterioration, emotional

instability, and spiritual

bankruptcy. Relapse

prevention and

educational

components.

Large-group therapy

dealing with 12-step

philosophy. denial,

recovering, cognitive

coping strategies, and

relapse prevention

skills. Small general

psychotherapy groups.

Personal counseling

minimum of 1 hour per

week. Academic/

vocational/UNlCOR

training. Peer

counseling for

advanced students.

Residential unit within a

security-level-two FCI

with single and muttlple

occupancy cells, dayrooms,

meeting rooms, exercise

area, and laundry

facilities. Staff offices

located within unit.

Separate from general

population Inmates.

Female inmates only.

10.5 hours treatment

78
Activities outside

program area

Number of

full-time program

staff

Number of total

program ‘slots’

Criteria for

selection

Education. vocational Education. vocational

training, or UNICOW training, or UNICOW

institutional job. AA/NA institutional job. AA/NA

meetings available meetings available

several times a week. several limes a week.

Meals and recreational Meals and recreational

activities same as other activities same as other

inmates. inmates.

12 10

90

-Randomly selected -Randomly selected

from list of volunteers. from list of volunteers.

-Meets clinical criteria -Meets clinical criteria

determined by ISUP determined by ISUP

score. score.

-20 lo 26 months until -20 to 26 months until

release. release.

-Approved for release -Approved for release

to SE region. to SE region.

-No outstanding legal -No outstanding legal

matters conflicting with matters conflicting with

halfway house slay. halfway house stay.

No serious medical, -No serious medical,

psychiatric, or psychiatric, or

psychological problems. psychological problems.

-No violent institution -No violent institution

infractions within 12 infractions within 12

months. months.

Urinalysis

monitoring

Yes

Program

duration

12 months

Time in BOPsupervised

aftercare

Up lo 6 months

Education, vocational

training, or UNICOW

institutional job. AA/NA

meetings available

several times a week.

Meals and recreational

activities same as other

Inmates.

12

105 150

-Randomly selected

from list of volunteers.

-Meets clinical criteria

determined by ISUP

score.

-20 to 26 months until

release.

-No outstanding legal

matters conflicting with

halfway house stay.

-No serious medical,

psychiatric, or

psychological problems.

-No violent institution

infractions within 12

months.

Yes Yes

12 months 12 months

Up to 6 months Up to 6 months

KEY: UNICOR=Federal Prison Industries

79
efforts. A description of the planned research can be found in Pelissier and

McCarthy (this volume).

Transitional Services (Community Reentry Phase)

Transitional services are provided after release from the prison environment to

both comprehensive and pilot residential program participants who successfully

complete the programs. (See table 1 for additional details.) The transitional

services delivery component consists of two phases. The first, prerelease

services, includes up to 6 months in a CCC, with specialized drug treatment

programing either contracted out or provided directly by BOP staff. The second

phase, aftercare services, consists of up to 6 months of community services

coordinated jointly by BOP and the Administrative Office of the U.S. Courts,

U.S. Probation Office. Several recommendations for service delivery have been

adopted for the transitional phase:

1.

2.

3.

4.

5.

6.

Individual and group counseling sessions for varying timeframes throughout

the 12-month period

Treatment focus on family/work adjustment, residential issues, and relapse

prevention planning (coping with high-risk events) through written

assignments and group discussions

Assistance in identifying and obtaining employment

Random urinalysis occurring with decreasing frequency over the 12-month

program duration

Documentation of all contacts by all service providers who are certified or

appropriately licensed

Transitional Care coordinators in each facility who arrange and monitor

service delivery

Inmates who successfully complete any residential program and who have a

good record of institutional conduct (no serious rule infractions) receive priority

for postrelease transitional services. These services are contracted in several

communities or operated directly by BOP personnel around the country in those

locations where inmates from the pilot and the comprehensive programs are to

be released.

80
SUMMARY

Developing high-quality treatment programs is a foreboding challenge in

any setting, particularly within a correctional setting. The groundwork has

been established for one of the most comprehensive, longitudinal evaluations

ever conducted with correctional populations regarding the effectiveness of

professionally managed treatment programs. The long-term outcome

evaluations should provide information regarding the effectiveness of a

multitiered intervention strategy within the correctional setting. This kind

of evaluation is reflected in the proposal for the evaluation of the BOP Drug

Abuse Treatment Programs, submitted to NIDA (Federal Bureau of Prisons

1990). In the months and years ahead the study is expected to yield important

information that will advance knowledge of substance abuse treatment.

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Lawson, G.W., and Lawson, A.W., eds. Alcoholism and Substance Abuse in

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Marlatt, G.A., and George, W.J. Relapse prevention: Introduction and overview

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Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention: Maintenance

Strategies in the Treatment of Addictive Behaviors. New York: Guilford

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narcotic addicts. J Nerv Ment Dis 173(2):94-102, 1985.

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manuscript, 1990.

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DHHS Pub. No. (ADM)86-1329. Washington, DC: Supt. of Docs., U.S.

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AUTHOR

Donald W. Murray, Jr., Ed.D.

National Drug Abuse Program Coordinator

Federal Bureau of Prisons

NALC Building, Suite 301

320 First Street, NW

Washington, DC 20534

83
Amity Righturn: A Demonstration

Drug Abuse Treatment Program for

Inmates and Parolees

David L. Winett, Rod Mullen, Lois L. Lowe, and

Elizabeth A. Missaklan

INTRODUCTION

In October 1990 inmates at the R.J. Donovan Correctional Facility (RJD)

near San Diego, CA, began the most ambitious prison and community-based

treatment program the California Department of Corrections (CDC) has

undertaken since the Civil Addict Program (CAP) was established 25 years

ago. Two hundred medium-security male inmates are participating in a

9- to 12-month prison-based therapeutic community (TC) called Amity

Righturn. Upon parole, approximately 60 program graduates continue

receiving treatment services in a 4-month community aftercare component.

This chapter focuses on developing the Righturn program as a CDC pilot

project to determine the effectiveness of a TC-based treatment program in

reducing drug and alcohol abuse and related problems among California’s

inmates and parolees. Also discussed are the rationale and planning process

for the Righturn program. As yet, no outcome evaluation data are available to

support the policies and strategies.

Given the severe increase in drug-related admissions to CDC, there may be

considerable value in examining the early development of this effort and in

reviewing the context in which Righturn has been undertaken. The impact

of increases in California’s inmate and parolee populations, changes in

administrative priorities within CDC, and a gradual shift in attitudes and

perceptions of “what works” for drug-involved offenders all contributed to the

decision to initiate the project. This chapter presents the basic components

of the Righturn program, both prison and community settings, along with a

preliminary description of accompanying research being developed to evaluate

this demonstration project.

The recency of California’s experience in developing this type of drug abuse

program may strike a resonant chord with others who are embarking on a

84
similar strategy, and this information may be relevant. Other State correctional

systems that are a step or two further along in analogous program development

and operations may be stimulated to share their experiences with CDC. In

addition, there may be opportunities for scientists and practitioners in the field

of corrections to learn about the short- and long-term effects of this program

through evaluations and careful analyses of findings.

SETTlNG THE STAGE

On September 27, 1987, California Governor George Deukmejian approved

legislation establishing a Blue Ribbon Commission on Inmate Population

Management. On January 29, 1990, a final report containing the Commission’s

analysis, findings, and recommendations was sent to the Governor and the

leadership of the State Legislature. Significant in the Commission’s findings

was that drug abuse is a major contributor to the increase in new commitments

and parole violators coming into California’s State prisons. In this regard, the

data provided in the report were striking.

The number of commitments to CDC with drugs as a primary offense had

grown from 3,890 in 1984 to 19,909 in 1988. As a percentage of all new

felon admissions, drug offenders increased from 11.1 percent in 1983 to

35.4 percent in 1988. In 1988, drug offense commitments became the

largest single category of felony commitments to CDC.

Drug use also has had a significant influence on parolees returned to prison.

According to the California Board of Prison Terms, in fiscal year 1988-89, drug

charges (illicit drug use) were a known factor in 58 percent of all revocation

actions, with substance abuse (illicit drugs) a contributing factor in more than

64 percent of parolees returned to custody for parole violations. The number of

parolees returned for drug or drug-related offenses grew from 850 in 1980 to

18,700 in 1988.

Such drug-related conditions have contributed to California’s current status

with regard to adult corrections programs. On August 1, 1990, more than

94,000 men and women were incarcerated in California’s State prisons, camps,

and community-based facilities, and another 65,000 were on parole. In 1994,

California’s prison inmate population is projected to reach more than 130,000,

with almost 84,000 parole violators being returned to prison annually. When

CDC’s current prison construction phase was completed in 1990, more than

37,000 beds were added system wide; but California’s prisons continue to be

overcrowded. In addition, CDC’s annual operations budget increased from

approximately $300 million in 1980 to about $1.8 billion in 1990 and is projected

to exceed $4 billion by fiscal year 1994-95. These large increases in CDC’s

85
populations and the growing costs of prison operations and construction, as

well as concerns about public safety and the secure management of inmates

and parolees, clearly argue that other options and program policies must be

explored to effectively manage drug-abusing offenders.

In the field of corrections, public safety and security of staff and inmates come

first. Therefore, until recently, prison construction and staff training have been

primary CDC priorities. In 1984 the first new beds constructed in the Nation’s

largest prison-building program came on line, thus helping to relieve unsafe and

overcrowded conditions in California’s older prisons, which were in desperate

need of repair and renovation. Between 1984 and 1994, more than 44,000

new prison beds-costing $3.2 billion-will have been built in California. This

rapid growth has required that thousands of new correction personnel be hired

and trained. There are almost 26,000 staff members in the CDC, an increase

of more than 100 percent since 1984. Major resources have been allocated

by CDC to ensure that line staff, supervisors, and managers are appropriately

trained for their difficult assignments. For many new staff members, this

training must take the place of valuable experience usually gained from

several years working on the “main line.”

Improving staff performance and constructing new prisons and renovating

older ones have helped. Since 1984, CDC records indicate that rates of inmate

assaults, staff assaulted by inmates, and serious incidents and inmate escapes

from prisons have decreased. CDC staff turnover has significantly decreased.

In 1984 staff turnover (staff who voluntarily left the Department) exceeded 14

percent of the work force. Today the number is 6.6 percent.

But rapidly expanding numbers of offenders, new prison construction, and an

increasing professionalism among corrections staff members were not sufficient

reasons to launch CDC into a new drug abuse treatment effort. What was still

lacking was a proven theoretical framework for drug abuse treatment that could

serve as an alternative to current conditions. Evaluations of correctional drug

abuse treatment in the 1960s and 1970s were not encouraging. They were

found to be limited and generally of poor quality (Lipton et al. 1975). Criticism

and calls for the rejection of correctional treatment programs peaked when

Robert Martinson’s article, “What Works? Questions and Answers About Prison

Reform,” was published in 1974. At the same time, common opinion held that

many prison drug treatment programs were poorly implemented and lacked the

essential principles of effective treatment (Camp and Camp 1989).

In the late 1980s CDC began to review studies and evaluations that presented

evidence that successful offender rehabilitation had been accomplished

(Gendreau and Ross 1987). Long-term studies of California’s CAP also

86
showed significant positive effects of the program during its period of full

operation in the mid-1980s (Anglin et al. 1987). Several studies suggested

that alternative approaches did exist for handling drug-dependent offenders

in the criminal justice system (Gendreau and Ross 1987; Leukefeld and Tims

1988.

In early 1989 CDC reviewed a promising program model in the work done

through Project REFORM. Project REFORM was established by a New

York-based research firm, Narcotic Drug Research, Inc. (NDRI); with funding

support from the Department of Justice, Bureau of Justice Assistance (BJA),

several programs were developed and/or supported. Chief among the Project

REFORM models is the Stay’n Out program in New York. This program was

the subject of a large-scale study that confirmed that a prison-based TC can

reduce recidivism. An 8-year evaluation study examined the progress of more

than 2,000 inmates who participated in the program and highlighted different

outcomes based on the type and duration of services received by inmates

(Wexler et al. 1985).

The Cornerstone program, located at the Oregon State Hospital, is another

excellent model. Although evaluated without an experimental design, findings

showed that the Cornerstone program successfully affected the lives of

chemically dependent recidivist offenders (Field, this volume; 1985).

Cornerstone, Stay'n Out, the Lantana Program in Florida, and the Simon

Fraser University Program in British Columbia were highlighted as four

promising approaches for working with drug-involved offenders (Chaiken

1989).

Another program that influenced CDC in the development of the Righturn

program was the Amity/Pima County Jail Project in Tucson, AZ. Through work

with jail inmates, Amity adapted the treatment components and methods used in

residential TCs to the correctional setting. This program has demonstrated that

a strong, productive working relationship can be developed between treatment

professionals (some of whom were ex-addicts/offenders) and correctional

personnel (Arbiter 1988). There are no outcome studies of the program,

although evaluations are planned. Chaiken, in her 1989 review of prison

programs for drug-involved offenders, identified noteworthy characteristics

among the four programs she studied. These included special and earmarked

funding, comprehensive approaches, use of staff from other professions besides

corrections, clear statements of program rules, obvious concerns by program

staff about the welfare of participants, staff as positive role models, postprison

preparation, and utilization of community resources (Chaiken 1989).

87
Douglas Lipton (Chief of Research for NDRI) listed, in addition to the items

noted by Chaiken, other necessary ingredients of a successful offender drug

treatment effort. These include treatment units isolated from the general prison

population, motivated participants, adequate treatment duration, frequent urine

testing, and continuity of postprison care (Lipton, this volume; 1983). Promising

results from other Project REFORM prison-based programs in Delaware (the

Key Program) and Alabama (New Outlook) also have provided support for

CDC’s development efforts.

In addition to these promising intervention programs, public opinion began

to focus again on the need for prisons to assist inmates in learning academic

and vocational skills and values that would help them reestablish themselves

as law-abiding citizens. The 1989 National Drug Control Strategy (Office of

National Drug Control Policy 1989) emphasized the importance of providing

treatment for drug-abusing offenders. Survey research reported in the

corrections literature also suggests that support for rehabilitation remains

strong among citizens (Cullen et al. 1988). And California’s Blue Ribbon

Commission strongly recommended the need for drug abuse treatment for

inmates and parolees (Blue Ribbon Commission on Inmate Population

Management 1990).

GETTlNG STARTED

CDC established an Office for Substance Abuse Programs (OSAP) in May

1989 to develop and coordinate departmental substance abuse programs.

Assisted by a BJA-funded invited review of CDC drug abuse treatment

needs (Rupp and Beck 1989) and a BJA planning grant, OSAP developed

a comprehensive treatment plan that was submitted to the State Legislature

in December 1989. Paramount in this plan is the Righturn demonstration

project at RJD.

RJD, located about 35 minutes from downtown San Diego (California’s second

largest city), was selected as a demonstration site because of the large number

of inmates committed from (and paroled back to) the San Diego area. This

localized flow will allow a sufficient number of inmates to continue their

corrections-based program participation in the community. Also, the Righturn

project will be able to include a specially trained group of parole agents in the

San Diego area to supervise the community component. Furthermore, the local

availability of a well-established community treatment network ensures access

to treatment personnel who can work inside the prison and in the community.

Finally, the choice of RJD was influenced by the willingness of the prison

warden, regional parole administrator, and their staffs to work with OSAP

and develop the demonstration project.

88
Four overall principles have guided program development. First, the program

must address the individual characteristics or “impedimenta” (D. Lipton,

personal communication, June 1989) or “criminogenic needs” (Andrews et al.

1989) of the participants. This principle is addressed through the careful

conduct (and ongoing review) of individual needs assessments. Second,

the program must be comprehensive enough to address the issues identified

in the initial needs assessment. This requirement means that the program

duration must be of sufficient length and the content flexible enough to meet

inmate and parolee needs. “One size fits all” doesn’t work in drug abuse

treatment. Third, treatment efforts must be sustained. Treatment continuity

from prison to parole and, if necessary, again in prison and back to parole

is essential. To facilitate the ability to sustain and continue treatment services

from one correctional environment to another requires that well-documented

records or treatment plans be maintained. To ensure this, the Righturn project

uses a Corrections Management Plan to chart inmate needs, assignment

of services, and treatment progress. Fourth, treatment efforts must be

carefully monitored and evaluated. Good evaluations must include a clear

understanding of program policies and procedures as well as agreement on

the importance of accurate, reliable, and relevant information systems.

Custody staff from RJD, parole agents from San Diego, and OSAP staff have

worked together to develop the prison and community program components.

At the same time, the proposed evaluation model (discussed below) is part

of the program development. The delivery of drug abuse treatment services is

provided by a community treatment agency that, when selected, will finalize the

program protocol.

Program Promotion and Inmate Selection

Because Righturn will be a voluntary program for inmates, the RJD staff uses a

Righturn video along with posters and announcements in classrooms, housing

units, and other areas to inform inmates about the project. Inmates interested

in participating in the demonstration project fill out an initial application form and

are screened by custody staff. Conditions that would exclude an inmate include

serious prison management problems, less than 9 months to parole, and less

than a fifth grade reading ability. Volunteers sign commitment contracts to

complete the whole program.

Length of Treatment

Based on the Stay’n Out experience, an appropriate length of participation in

a prison TC appears to be around 9 months (Wexler et al. 1985). Participants

in the prison program move through three different phases of treatment. The

89
first phase (approximately 2 to 3 months) begins assimilating the inmate into

the project and into full participation in all activities: vocational, therapeutic,

and social. Inmates begin to gain an understanding of their underlying

problems and learn the use of encounter groups, peer structure, and other

TC basics. They are assigned to their prison industry job as well as other

unit duties. More experienced inmates (those in the project for a longer

period) are assigned to function in a supportive role for the new inmate

who is experiencing adjustment difficulty.

The second phase (5 to 6 months) focuses on objectives of personal

growth, socialization, and psychological awareness. Inmates are expected

to improve in their understanding of self and others and to work consistently

and productively, taking on additional program responsibilities by functioning

as role models and surrogate “big brothers” for newer inmates. As the inmate

progresses, he should become more accomplished as an encounter group

participant and facilitator and more self-disclosing, thereby helping himself

and others in the project. During the exit and community reentry phase (1 to

2 months), inmates strengthen skills for autonomous decisionmaking and selfmanagement. Inmates participate in intensive relapse prevention training and

participate with correctional and treatment staff in developing their individualized

exit plan (Mullen 1990).

Treatment Components

Treatment components for the three phases include individual counseling,

vocational training, group sessions, video playback, special topic workshops,

expressive therapy, leisure planning, assistance with academic programs, and

transition planning for community reentry.

In addition to these components, and in keeping with the idea of isolating

program participants from the general prison population, Righturn inmates

are assigned to work in a single prison industry. The inmate’s industry work

assignments increase in responsibility and accountability as he or she

progresses through the program phases. Because much of the TC model

is founded on the 12 steps to recovery programs of Alcoholics Anonymous,

Narcotics Anonymous, and Cocaine Anonymous, meetings of these three

groups are included throughout the duration of treatment.

Staff Selection and Training

Most of the staff designing the program will work in the program when it starts.

RJD also has received many requests from custody staff for assignment to the

Righturn project. All RJD staff members are instructed in the overall program

90
aspects, and those assigned to the project receive special training from the

treatment provider. The treatment staff also receives intensive instruction in

the custody and security policies and procedures of the institution.

SUSTAINING THE EFFORT

Without consistent treatment, research has shown that as many as two-thirds

of drug-dependent offenders can be expected to return to patterns of chronic

drug use and associated crime within the first 3 months of release from jail

(Wexler et al. 1988). The revocation numbers discussed earlier in this chapter

attest to the high rate of recidivism experienced by CDC. The Righturn project

is attempting to successfully intervene during this critical period by including a

4-month community treatment component for program participants paroling to

San Diego (approximately 60 inmates). The project’s community treatment

phase starts in a residential TC and continues the treatment strategies begun

in prison. Participation in this treatment phase is included as one of the

parolee’s conditions of parole and actively involves the participant, his or her

parole agent, and the treatment program staff. There is considerable evidence

that closely linking participation with legal sanctions (a condition of parole) is

effective in keeping the offender in treatment (Anglin and McGlothlin 1984)

and that increased time in treatment is associated with successful outcomes

(Hubbard et al. 1988. 1989). Both public safety and individual benefits occur

by keeping drug-using offenders in treatment. A policy that focuses on applying

appropriate interventions has the potential to reduce the offender’s criminal

activity and to reduce the likelihood of subsequent incarceration (Wish 1988).

PROGRAM EVALUATION

Chaiken (1989) has pointed out that none of the four programs she studied

used designs incorporating random assignment or adequate statistical

techniques, and she has stressed a need for more rigorous program

evaluations. The Righturn demonstration project proposes a rigorous

evaluation. A quasi-experimental design for outcome evaluation is planned

to examine the effectiveness of the Righturn program. The basic question

to be answered by the evaluation is: “Is the project, with and without a

continuation of community treatment, effective in reducing drug use by

offenders, resulting in fewer parole revocations?” To answer this question,

data are being collected from three research groups: (1) inmates who

participate in the in-prison program and also in San Diego community services

after prison parole, (2) inmates who participate in the in-prison program only,

and (3) a group of inmates who are eligible for the program but are not selected

to participate. The third group serves as a comparison group.

91

318-269 0 - 92 - 4 QL3
The original research question is separated into five major areas:

1.

2.

3.

4.

5.

What effect does the Righturn drug treatment program have on

parole outcome (e.g., arrests, technical violations, and length of time

to revocation)? To answer this question, findings for each of the three

outcome variables for the program participants will be compared with

these of the control group.

What effect does the postprison (community) drug treatment component

have on parole outcome (arrests, technical violations, and length of time

to revocation)? To determine the effect of Righturn on participants who

continue treatment services in community drug treatment, outcome for

those who receive community services will be compared with that of

participants who do not receive postprison treatment services.

What effect does the Righturn in-prison TC and postprison community

drug treatment have on long-term outcomes (1 to 3 years postprison) in

terms of parole revocations and of returns to prison for a new offense?

This question attempts to determine the lasting effect of the program for

the three primary research groups and will rely on data from standard

CDC and Board of Prison Terms data files.

Are there cost savings attributable to the in-prison and postprison

community substance abuse treatment program?

It is anticipated that program participants will remain drug-free and

crime-free on parole far more days than parolees who do not participate

in drug treatment. Associated costs include reduced numbers of parole

revocations, fewer prison days due to revocation, and reduced criminal

activity. Cost comparisons will be made for each of the three research

groups.

Are there in-prison management benefits for program participants, such

as fewer serious disciplinary incidents and fewer good time credit days

lost? It is expected that the semi-isolation and highly structured program

environment will reduce prison management problems among the

participants.

Study Sample

It is expected that 250 to 400 inmate volunteers will be eligible to participate

in the project. Of the total, 200 will be assigned to the Righturn program;

the balance will participate as control subjects. Of the 200 participants,

92
approximately half will parole to San Diego County; the rest will parole

elsewhere within the State.

The selection of project participants will ensure that the ethnic composition

of the treatment and control groups will approximate that of the RJD inmate

population. Inmates who will parole to San Diego are divided almost equally

into three ethnic groups: black, Hispanic, and white. The ethnic composition

of those paroling elsewhere in the State is different, with a slightly higher

percentage of blacks and Hispanics and a noticeably smaller percentage

of whites. Efforts will be made to correct this by stratified sampling.

Subject ldentification and Recruitment

RJD staff will identify inmates who meet the following selection criteria:

volunteer to participate in substance abuse treatment, have a substance

abuse problem, have no history of violence, have at least a fifth grade

reading ability, are nearing the end of confinement, and have sufficient

time to complete the program.

Since community services will be provided in San Diego County, an

additional requirement is that about half of the eligible volunteers must

have been committed from, and plan to return to, San Diego County. When

interested inmates are identified, RJD staff will invite them to attend a group

meeting describing the Righturn program. Those who attend will be invited

to volunteer for the program. Recognizing that inmates may be reluctant

to volunteer in the presence of a group, inmates also will be interviewed

individually. Inmates who volunteer will be considered for participation in

the evaluation study, either as a program participant or as a control subject.

Research subjects will be selected from two pools of inmates potentially

eligible for participation in the in-prison program: those who parole to San

Diego County vs. the balance who parole outside San Diego. Research

subjects will be assigned to each of the three comparative groups.

Sampling

Early evaluation plans for the Righturn project called for an experimental design

using random assignment of participants to treatment and control groups. This

design is recommended by Campbell and Stanley (1966) since it provides

control for both internal and external validity. Hubbard and colleagues (1989)

found random assignment inappropriate for the national long-term Treatment

Outcome Prospective Study (TOPS) because it would create artificial selection

conditions not typical of treatment atmospheres, thereby limiting generalizability

93
to community treatments. A large number of community programs nationwide

were represented in TOPS, which reported that, although it is difficult to

separate treatment effect from the effect of self-selection without a randomly

assigned comparison group, causalty can be inferred through careful statistical

analysis (Hubbard et al. 1989).

In contrast to the multitude of programs represented in TOPS, the Righturn

study will examine only one in-prison program and a few community programs.

Therefore, the randomized groups experimental design was considered more

suitable for this evaluation study.

However, as planning moved closer to actual implementation, changes

became necessary, and a quasi-experimental design has been developed

instead. Two significant issues contributed to the development of this

design. The first issue was the insufficient number of eligible program

volunteers to establish random assignment to treatment and control groups.

Afler a careful review of inmate files, it was determined that only 350 to 400

of the inmates at RJD (10 to 15 percent of the general population) met the

project criteria regarding time remaining in prison prior to parole, no history

of violence, a history of substance abuse problems, and at least a fifth

grade reading level. When the “volunteer” criterion was applied, many

otherwise eligible inmates decided not to enter the program, thus revealing

an interesting phenomenon of prison inmate life (and reducing the pool of

program participants).

During initial Righturn program orientations, prison staff observed that

some inmates, upon learning about the program and its possible benefits,

were unwilling to change their daily routines. In many cases, participation

in Righturn will result in an inmate changing his housing unit and job or

education assignments and also may require socialization with other inmates

Prison officials believe that many inmates probably will adopt a wait-and-see

attitude about this new program before accepting these major disruptions in

their prison life.

The second issue concerns the possibility of assigning to a program inmates

who, in the opinion of the treatment staff, lack the essential qualities for program

success. Because of this, the first assignment of project participants will be

done through a careful screening of program applicants by the institution and

treatment staff.

An initial comparison group of 200 inmates will be composed of eligible

inmates who did not volunteer for the program as well as those who were

screened out of the treatment group. It is expected that, by the sixth or

94
seventh month of project operation, randomized assignment will be used

for new project participants.

It is also important to note that the evaluation model proposed for this project

is being developed at the same time as the project. Because custody and

treatment staffs are involved with the design, it is hoped that many problems

identified in other correctional programs’ field experiments will be avoided

(Petersilia 1989).

CONCLUSION

The Righturn project offers the State of California as well as the corrections

field in general an excellent opportunity to learn about the effectiveness of

a corrections-based, drug-abusing offender treatment program. The CDC

recognizes the complexities associated with this demonstration project.

However, the knowledge gained from the successful REFORM projects

and other efforts as well as work on why similar programs failed (Camp

and Camp 1989) should greatly assist CDC with its present effort.

Numerous implementation problems exist, one of which is the availability of

treatment resources needed for continuity of care in the San Diego area. CDC

and San Diego County representatives will have to work carefully together to

ensure sufficient treatment opportunities. Even with additional funding for the

demonstration project participants, failure to develop new treatment services

in San Diego, particularly residential treatment beds, will seriously affect the

project. Potential conflict may develop if competition occurs for treatment beds

between non-criminal justice clients and “ex-cons.”

Another concern is the need for patience. Public safety and the protection

of staff and inmates remain the primary mission of the CDC. To ensure this,

the conduct of drug abuse treatment for inmates and parolees must be carried

out very carefully, in a well-planned way with specially trained and supervised

custody and treatment personnel. Thus, extensive and time-consuming

program development and training efforts are required. There are no quick

fixes or miracle cures in dealing with this difficult population. The drug

abuse-involved offender is an extremely high risk to society as well as

an individual who is very reluctant to enter, remain, and succeed in drug

abuse treatment. Because of this, funding decisions by State legislatures

and administrators must be of sufficient amount and duration to achieve the

desired outcome.

But no matter how difficult, and at times discouraging, the program

development seems, competent attempts must be made. At a presentation

95
in San Diego to CDC wardens and parole administrators at an OSAPsponsored substance abuse conference on June 15, 1989, Lipton summed

up the importance of implementing these kinds of programs: “Just serving time

degenerates men and their keepers inexorably. Use time as an opportunity for

change, It values both of them and eventually alters the quality of life for all

humankind” (Lipton 1989).

REFERENCES

Andrews, D.A.; Zinger, I.; Hoge, R.D.; Bonta, J.; Gendreau, P.; and Cullen,

F.T. “Does Correctional Treatment Work? A Clinically-Relevant and

Psychologically Informed Meta Analysis.” Paper presented at the Research

Seminar of Natural Associations ACRIVE in Criminal Justice, Ottawa,

Canada, 1989.

Anglin, D.; Deschenes, E.; and Speckart, G. “The Effect of Narcotic Addiction

and Criminal Behavior.” Paper presented at the American Society of

Criminology Annual Meeting, Montreal, Canada, November 1987.

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict treatment in

California. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment

Evaluation: Strategies, Progress, and Prospects. National Institute on Drug

Abuse Research Monograph 51. DHHS Pub. No. (ADM)86-1329.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 106-128.

Arbiter, N. Drug treatment in a direct supervision jail: Pima County’s Amity Jail

Project. Am Jails 2(2):35-36, 39-40, 1988.

Blue Ribbon Commission on Inmate Population Management. “Blue Ribbon

Commission on Inmate Population Management: Final Report.” Report

submitted to the Office of the Governor of California, Sacramento, CA, 1990.

Camp, G.M., and Camp, C.G. Building On Prior Experience: Therapeutic

Communities in Prisons. South Salem, NY: Criminal Justice Institute, 1989.

Campbell, D.T., and Stanley, J.C. Experimental and Quasi-Experimental

Designs for Research. Boston: Houghton Mifflin, 1966.

Chaiken, M. In-Prison Programs for Drug-Involved Offenders. Washington,

DC: National Institute of Justice, U.S. Department of Justice, 1989.

Cullen, F.; Cullen, J.; and Wozniak, J. Is rehabilitation dead? The myth of the

punitive public. J Crim Justice 16:303-317, 1988.

Field, G. The Cornerstone program: A client outcome study. fed Probation

49:50-55, 1985.

Gendreau, P., and Ross, R. Revivification of rehabilitation: Evidence from the

1980s. Justice Q 4(3):349-407, 1987.

Hubbard, R.L.; Collins, J.J.; Rachal, J.V.; and Cavanaugh, E.R. The criminal

justice client in drug abuse treatment. In: Leukefeld, C.G., and Tims, F.M.,

eds. Compulsory Treatment of Drug Abuse: Research and Clinical Practice.

National Institute on Drug Abuse Research Monograph 86. DHHS Pub. No.

96
(ADM)89-1578. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988. pp. 57-80.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; and Cavanaugh,

E.R. Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill,

NC: University of North Carolina Press, 1989.

Leukefeld, C.G., and Tims, F.M. Compulsory treatment: A review of findings.

In: Leukefeld, C.G., and Tims, F.M., eds. Compulsory Treatment of Drug

Abuse: Research and Clinical Practice. National Institute on Drug Abuse

Research Monograph 86. DHHS Pub. No. (ADM)89-1578. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 236-251.

Lipton, D. “Important Conditions for Successful Rehabilitation.” Paper

presented at the 1983 Bellevue Forensic Psychiatric Conference, New York,

1983.

Lipton, D. “Continuity of Care.” Paper presented at the California Department

of Corrections “Creating a Sense of Optimism: A Substance Abuse

Seminar,” San Diego, CA, June 15, 1989.

Lipton, D.; Martinson, R.; and Wilks, J. The Effectiveness of Correctional

Treatment. New York: Praeger, 1975.

Martinson, R. What works? Questions and answers about prison reform.

Public Interest 35:22-54, 1974.

Mullen, R. “Drug Abuse Offender Demonstration Project.” Proposal submitted

to the Department of Corrections, Sacramento, CA, 1990.

Office of National Drug Control Policy. National Drug Control Strategy. Report

No. S/N 040-000-00542-1. The White House. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., September 1989.

Petersilia, J. Implementing randomized experiments. Eval Rev 13(5):435-458,

1989.

Rupp, L.G., and Beck, A.R. Invited Review: California Department of

Corrections Substance Abuse Programming. Washington, DC: Bureau

of Justice Assistance, 1989.

Wexler, H.K.; Lipton, D.S.; and Foster, K. “Outcome Evaluation of a Prison

Therapeutic Community for Substance Abuse Treatment: Preliminary

Results.” Paper presented at the American Society of Criminology Annual

Meeting, San Diego, CA, November 1985.

Wexler, H.K.; Lipton, D.S.; and Johnson, B.D. A Criminal Justice System

Strategy for Treating Cocaine-Heroin Abusing Offenders in Custody.

Washington, DC: National Institute of Justice, 1988.

Wish, E.D. Identifying drug-abusing criminals. In: Leukefeld, C.G., and Tims,

F.M., eds. Compulsory Treatment of Drug Abuse: Research and Clinical

Practice. National Institute on Drug Abuse Research Monograph 86. DHHS

Pub. No. (ADM)89-1578. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1988. pp. 139-159.

97
AUTHORS

David L. Winett, B.A.

Assistant Director

Lois L. Lowe, Ph.D.

Research Specialist

Off ice of Substance Abuse Programs

California Department of Corrections

P.O. Box 942883

Sacramento, CA 94283-0001

Rod Mullen

Executive Director

Amity, Inc.

P.O. Box 60520

Tucson, AZ 85751-6520

Elizabeth A. Missakian, Ph.D., L.L.B.

Program Director

Amity/Righturn

Suite 160

444 West C Street

San Diego, CA 92101

98
Substance Abuse Services in Juvenile

Justice: The Washington Experience

David Brenna

INTRODUCTION

In 1984, the Division of Juvenile Rehabilitation (DJR) in Washington State

issued a report that dramaticaIly changed the way the agency viewed its client

population. By 1985, a full range of services for clients involved with alcohol

and other drugs began operating. In late 1989, DJR conducted an agency-wide

needs assessment that provided the opportunity for line staff members to report

their opinions of division programing. Among the results: Alcohol and other

drug services were ranked first in importance and effectiveness when compared

to all other programing offered by the agency.

This chapter describes the substance abuse programs in Washington State,

the DJR, and a system perspective on the development of such programing

that supports its replication in other juvenile justice systems. Research findings

in the field of adolescent and/or youthful offender substance abuse treatment

conducted by DJR are discussed. Finally, existing service gaps are identified

and recommendations for future direction are proposed.

Substance abuse treatment within juvenile justice systems is a natural evolution

of the demands of the dual goals of offender accountability and rehabilitation.

From 1984 to the present, the “Washington experience” has been one of

growth, change, and discovery.

STATEMENT OF THE PROBLEM

Substance abuse problems are prevalent in the juvenile justice client

population, including those in training schools, detention facilities, and

day treatment programs. Many studies have established the link between

substance abuse and delinquency (Clayton 1981; Jessor 1976; Leukefeld

and Clayton 1979; Simonds and Kashani 1979). In a study of adult criminal

offenders, Chaiken and Chaiken (1982) found serious and dangerous offenders

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were most typically addicted to alcohol and/or illicit drugs. Frequency of

criminal behavior also is linked to drug use (Ball et al. 1983; Gropper 1985).

In juvenile studies, significant findings include the link between violent

offenses and substance use (Hartstone and Hansen 1984), drug abuse rate

and predicting offense type (Simonds and Kashani 1979), extensive alcohol

use in juvenile correction populations (Dawkins and Dawkins 1983), and high

rates of toxicity in juveniles at time of arrest (Wish 1988). Juvenile offender

populations typically show 70 percent or more having a serious alcohol or

illicit drug problem (Inciardi 1981; Santo et al. 1980). Client use is identified

as a major issue in rehabilitation effectiveness, group control, and staff security

(Fagan and Hartstone 1984). Finally, within the Washington experience,

studies have demonstrated high rates of assessed chemical dependency

among the delinquent, incarcerated population (Guthmann and Brenna

1990). A further discussion of the studies conducted in Washington State

can be found later in this chapter in the section on research and evaluation.

Given current knowledge about criminality and alcohol/other drug abuse,

it is clear that little of the existing empirical knowledge is based on adolescents

(Catalano et al., unpublished manuscript). While some outcome studies

suggest optimism in treating substance abuse (Hubbard et al. 1985), there is a

limited literature that adequately describes treatment approaches or outcomes

with a juvenile offender client population. The drug/crime link, though well

established, remains undefined. Assumptions about the value of treatment to

this offender population presumes a semicausal relationship. Washington State

answered this challenge with a “best practices” approach leading to the current

configuration of services.

A most important issue concerns the impact of juvenile justice systems on

the treatment of the substance abuser. Juvenile justice programs typically

are reluctant to develop new approaches. In addition, members of the

juvenile justice profession tend to reflect the attitudes and values of the larger

society-a disturbing thought when contemplating substance abuse. DJR had

experienced difficulty in contracting for substance abuse services and had

canceled service contracts. The 1983-84 Task Force found ample evidence to

recommend (1) ownership of the “problem” by juvenile justice professionals and

(2) internal system change to reflect new attitudes and values about substance

abuse. Presuming that rates of substance problems among employees would

mirror those in the general population, these changes would have ramifications

exceeding the staffs professional role. Finally, adolescent denial demands a

total investment in drug-free environments if treatment is to be effective.

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PROGRAM DESCRIPTION

The Washington experience began with the development of a mode.

The most significant and difficult service implementation barriers involved

attitudes and values, as well as the interplay of two philosophical perspectives,

substance abuse treatment and juvenile justice, which are often at odds.

The treatment perspective presumes juvenile corrections to be punitive. The

justice perspective presumes treatment to be unaccountable. The great irony,

and the story of change in DJR, is how the two views complement each other.

Substance abuse treatment, when applied effectively, is based on the ultimate

accountability of the client to manage his or her disease. Juvenile justice, when

managed proactively, strives to rehabilitate offenders. When trained in the use

of substance abuse treatment interventions, juvenile justice professionals

become quite adept at offender accountability-directed recovery. Treatment

professionals find an entire system capable of monitoring and supporting the

client’s recovery.

However, system changes were slow to develop, and they continue to evolve

now. A key philosophical position, adopted in 1986 and supported by DJR

leadership, is important:

All research based data currently available shows positive

correlation between delinquency and substance abuse. This

correlation is unclear in nature. As study continues, the

correlation strongly suggests that without addressing both

behaviors (criminality and substance abuse) the likelihood of

alleviating either behavior is low. Additionally, the subjective

analysis of working professionals points to the need for

substance abuse treatment for their clients. The correlation

data and subjective analysis both indicate promise for a

reduction in recidivism through treatment of substance abuse

(Division of Juvenile Rehabilitation 1986).

The statement is important in the adoption of juvenile justice goals for the DJR

program components. The agency rationale for operating treatment services

remains congruent with the DJR stated mission. If a youth continues drug use

but ceases criminal behavior, the pure justice goal of treatment would be met.

However, if a youth remains in recovery from chemical dependency but

continues criminal activity, the justice goal of treatment has not been met.

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The relationship of juvenile justice goals to the system’s specialized treatment

approaches is critically important in meeting agency goals. By indicating

their position, the DJR leadership settled the fundamental question: Why are

treatment services offered? They created an expectation for future research to

support or refute the effectiveness of treatment in reducing criminal recidivism.

Furthermore, the philosophical position established the direction for system

change. Two important concepts emerged: (1) The model was to be an

“integrated services” approach, and (2) the model would be a “case find”

approach instead of a “gate keep” approach. The “case find” approach differs

from “gate keep” because treatment clients are actively sought rather than

client levels being determined by budget limitations. Based on the philosophy

of “case find,” all youth in need of service are identified. Resource limitations

are answered by tailoring certain low-cost alternatives to clients who might

respond, while identifying most-in-need clients for the most intensive services.

As the term implies, integrated services ensure ownership of the substance

abuse problem by the host agency. In the Washington experience, juvenile

justice staff members are designated to perform various case management

and treatment functions. Integrated services mean that (1) individual cottages

on institution campuses have been converted to free-standing, inpatient

chemical dependency programs; (2) specialist staff personnel were hired

and assigned to coordinate and provide treatment services to the entire

client population; (3) education specific to offender substance abusers was

developed and delivered by institution school programs; (4) assessment for

chemical dependency is conducted by juvenile justice diagnostic staff; and

(5) onsite drug detection is managed by DJR. Contracted services are

provided in many community locations; however, the bulk of services are

funded and operated by DJR. Alcohol and illicit drug programs in DJR are

viewed as a component of the system, not as an ancillary service.

COMPONENTS

The model incorporates a continuum of services based on client dysfunction

level. Service components were applied to each category of abuser, based on

assessment, and layered to the next, more dysfunctional level of abuser, from

nonuse through chemical dependence. Assessment, education, and residential

chemically free environments were the nonuser components. The casual or

situational user received all the previous components plus urinalysis monitoring,

information groups, and referral. Intensive services, including intervention,

outpatient treatment, inpatient treatment, and aftercare are available for clients

seriously involved with substances.

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Describing service components was perhaps the easiest task, but

implementation began slowly and encountered numerous obstacles. Many

problems were resource issues; some were policy issues. The substance

abuse program in Washington’s juvenile system is best described by its

component parts: assessment, education, intervention, treatment, and

continuing care.

Assessment occurs at each DJR level and is supported by an offense-specific

case management approach that predates the development of the substance

abuse program. At 18 diagnostic centers throughout the State, the Personal

Experience Screen Questionnaire (PESQ) (Winters and Henly 1989) is

administered to each youth committed to the State Division of Juvenile

Rehabilitation. The PESQ is a 38-item screening instrument that “flags” clients

who might be experiencing difficulty with substances, It supports the Personal

Experience Inventory (PEI) developed by Winters and Henly (1987). A youth

identified for further assessment by the PESQ receives the full PEI at or shortly

after admission in one of five State institutions. Assessment and interpretation

are conducted by specialists located at the institutions. These chemical

dependency coordinators play a critical service delivery and case management

role throughout the division. Information from the PESO and the PEI is

compiled in individual case files and excerpted in Initial Treatment Reports and

ongoing treatment updates. At their request, youth can be reassessed at

request at any time during their stay. The PEI provides an indepth, validated

analysis of responses by youth, pinpointing their level of chemical involvement

and a variety of treatment issues, including social and psychological functioning

Education is provided to each youth within DJR’s school programs. In 1985

DJR began the development of the Innervisions curriculum. Innervisions

evolved as a result of teacher frustration with mainstream prevention curricula;

a heavily involved delinquent population did not respond to material designed

for “normal” youth. Innervisions focuses both the teacher and the youth on

an exploration of family and chemical dependency issues. Close working

relationships are required between teachers and counseling staff members to

make the curricula viable. DJR recently has contracted with a private concern

to market the Innervisions package. Keys to Excellence, Inc., will publish and

distribute the Innervisions curriculum and provide training support.

Intervention is an important and challenging system issue for juvenile justice.

A key element of the successful alcohol/other drug program is the imposition of

values and expectations on all clientele. As staff members in authority and as

adult role models, staff attitudes and their expression are essential to consistent

care. The concept of continuum of care is facilitated directly by intervention

methods applied evenly throughout the system. lntervention includes the

following approaches:

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1. Clarification of attitudes about drugs by all staff

2. Written policy that outlines conformance with those attitudes

3. Natural and logical consequences for client misbehavior

4. Provision of a drug-free environment for youth

Staff attitudes and societal attitudes greatly affect adolescent attitudes and

values toward alcohol and other drug consumption. Consuming substances

is a choice that must be made responsibly, with the full understanding of the

consequences of that choice. A consequence of adolescent consumption of

illicit substances includes punitive measures applied by staff representing

DJR. Clients are not protected from these consequences. Attitudes about

illicit drugs and alcohol also are subjected to consequences within this system,

making it imperative that staff attitudes are explored and honestly addressed

by supervisors and coworkers. Written guidelines ensure that sanctions are

applied evenly so that use and drug/alcohol values are addressed with action.

DJR’s treatment programs consist of two essential components. Outpatient

models are provided at each residential program by in-house counseling staff,

specially trained in group treatment for chemical dependency clients. Chemical

dependency coordinators organize, schedule, and implement treatment groups

that are cofacilitated by regular counseling staff. The following is a partial list of

groups offered by institution programs:

Drug Use Consequences Group

Intervention Group

Information Group

Responsibility Group

Family Group-Children of Alcoholics

Family Workshop

Intervention/Return to Use

12-Step Groups

12-Step Information Group

Aftercare, Recovery

Continuing Care, Relapse

Relapse Prevention

Recreational/Therapy Group

Spirituality

Chemical Dependency Treatment Group

Pretreatment Group

“Dual Diagnosis”

Codependency/Relationships

Young Entrepreneurs Group

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Inpatient treatment is the focal point for much of what occurs in DJR’s

programing. Three separate centers-Exodus, Omni, and Parke Creek-are

short-term, multistrategy intensive treatment units. Exodus and Omni are

located on institution campuses, whereas Parke Creek is community based

and is located in rural central Washington. Omni and Exodus have virtually

identical programing except that Exodus is co-ed. Parke Creek is shorter term

and works with community commitment from the juvenile court system, as

well as with State-committed youth. Each program has 16 beds. Sixty days

of treatment are offered at Omni and Exodus and 30 days at Parke Creek.

Treatment approaches are based on the Hazeldon model, following the

12-step approaches of Alcoholics Anonymous (AA) and Narcotics Anonymous

(NA). All three programs are State certified. The programs were developed

by taking an existing cottage program off line, enriching the staff complement,

providing extensive training, and reopening as resources for DJR’s clients.

Youth must be serving a sentence for a juvenile court commitment and be

referred by their assigned counselor. Following treatment, youth are returned

to the sending institution or transfered to a recovery-based group home for

aftercare.

Aftercare or continuing care is provided by institution programs for long-term

offenders or by community residential programs operated or contracted by

DJR. Programing consists of the AA/NA 12-step approaches with access to

community meetings, treatment groups, and individual counseling in addition

to regular programing for preparing youth for release. Regular urinalysis is

an important component of the DJR continuing care model. DJR utilizes

fluorescence polarization immunoassay as its testing methodology, with onsite

testing labs at every State residential facility, including some parole offices.

Parole offers some continuing care to the recovering youth, including access

to treatment groups, AA, NA, and case monitoring. Linkage to available local

services is critical for the youth finishing his or her commitment.

An important development occurred in Washington State in 1989 when the

legislature, through the Omnibus Alcohol and Controlled Substances Act,

provided funds to replicate inpatient service components in the State’s 18

county juvenile detention centers. Programs vary greatly, from assessment

and referral centers to complete, short-term inpatient programs, segregating

treatment clients from the general population. It is too early to ascertain the

viability of these programs developed in late 1989; however, current information

suggests that, with some fine tuning, detention programing offers exciting

opportunities for treatment of a client population otherwise difficult to serve.

Program administration is the responsibility of a central office administrator. To

support system changes and to respond to technical and policy questions, the

105
Substance Abuse Oversight Committee was developed. This committee plays

an advisory role, making policy and program recommendations for needed

change.

RESEARCH AND EVALUATION

DJR has participated in two important studies in the area of substance

abuse treatment and juvenile corrections. In 1985, DJR contracted with the

University of Washington to conduct a literature review on substance abuse

treatment in the criminal justice system. At the same time, Hawkins and

colleagues (1986) were conducting a study called project ADAPT (Adolescent

Drug Abuse Treatment and Early Intervention Project), providing a model for

transition services with DJR clients. ADAPT was part of a series of efforts by

Hawkins and coworkers that culminated in a model of risk-based approaches

for identification and treatment of adolescent substance abusers (Hawkins

et al. 1986).

In 1988, DJR completed a study of the PEI to determine the validity of the

instrument when used with a chronic delinquent population (Guthmann and

Brenna 1990). That same study led to an analysis of the same data sets

that disclosed valuable information on the extent and nature of substance

abuse among a juvenile offender client group (Brenna and Steiger,

unpublished manuscript). The initial study found the PEI to be valid with a

delinquent population, with the clinical norms for the offenders ranging as

high as seven standard deviations more than an adolescent drug treatment

population. Subsequent analysis revealed that 80 percent of the incarcerated

population exhibited serious drug/alcohol impairment. Although this information

did not surprise practitioners in the Washington juvenile justice system, the

implications for further program development are significant. Although all

substance-abusing adolescents may not be delinquent, it appears that most

delinquents are substance abusers, suggesting that failure to address

substance abuse in this population almost ensures minimum impact on

recidivism.

It also should be noted that DJR is seeking support from the National Institute

of Justice to conduct a study, using an experimental design, to examine the

effectiveness of drug testing and treatment on a juvenile probation population.

Court-ordered youths will be assigned randomly to one of four interventions:

traditional probation, probation with treatment, probation with drug testing

and sanctions, and probation with drug testing, sanctions, and treatment.

Washington has been selected as the study site. It is expected that this

study will produce results previously unavailable to the field.

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FUTURE DIRECTIONS

In 5 years of the Washington experience, each change in the State’s Juvenile

Justice Substance Abuse Programs has multiplied the areas of concern and

interest on the part of professionals working in these programs. As a result,

several important issues demand future attention, including those identified

below. County-based treatment services in detention currently being

implemented will answer significant questions about the amenability of the

youthful offender to early intervention, with the hope of using treatment to

reduce further criminality and subsequent, more serious involvement with the

criminal justice system. The adolescent treatment field generally is plagued by

the question of the relative value of outpatient treatment in light of soaring costs

for inpatient care. Urinalysis monitoring raises interesting questions, as does

the use of other forms of detection in combination with new technologies such

as electronic monitoring.

Another major focus of concern is providing culturally relevant services. The

substance abuse treatment field generally has reflected the cultural bias of

the majority culture. In juvenile corrections, minority groups comprise large

segments of the client population in need of treatment. Recognizing this, the

Washington State Substance Abuse Oversight Committee commissioned a

work group to examine current practice and research on culturally specific

treatment modalities and to produce recommendations for changes.

The Washington experience has produced a surprisingly straightforward model

that has been accepted by the entire system. Second-generation issues and

outcome-based research are playing a role in advancing these programs and

are providing a model for other systems.

REFERENCES

Ball, J.C.; Shaffer, J.W.; and Nurco, D.N. Day-to-day criminality of heroin

addicts in Baltimore: A study in the continuity of offense rates. Drug Alcohol

Depend 12:119-142, 1983.

Brenna, D., and Steiger, J. “The Impact of Substance Abuse on a Delinquent

Population.” Unpublished manuscript.

Catalano, R.F.; Hawkins, J.D.; Wells, E.A.; Miller, J.; and Brewer, D.

“Evaluation of the Effectiveness of Adolescent Drug Abuse Treatment,

Assessment of Risks for Relapse, and Promising Approaches for Relapse

Prevention.” Unpublished manuscript.

Chaiken, J.M., and Chaiken, M.R. Varieties of Criminal Behavior. Santa

Monica, CA: Rand Report, 1982.

107
Clayton, R.R. The deliquency and drug use relationship among adolescents:

A critical review. In: Lerrier, D., and Ludford, J., eds. Drug Abuse and the

American Adolescent. National Institute on Drug Abuse Research

Monograph 38. DHHS Pub. No. (ADM)81-1166. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1981. pp. 82-103.

Dawkins, R.L., and Dawkins, M.P. Alcohol use among black, white and

Hispanic adolescent offenders. Adolescence 18(72):799-810, 1983.

Division of Juvenile Rehabilitation. ‘Substance Abuse Task Force Report.”

Olympia, WA: Division of Juvenile Rehabilitation, April 1986.

Fagan, J.A., and Hartstone, E. “Dilemmas in Juvenile Corrections: Treatment

lnterventions for Youth With Alcohol, Drug Abuse, and Mental Health

Problems.” Paper presented at ADAMHA Conference on State-of-the-Art

Research on Juvenile Offenders With Drug Abuse, Alcohol, and Mental

Health Problems, Rockville, MD, 1984.

Gropper, B. Probing the Links Between Drugs and Crime. Washington, DC:

U.S. Department of Justice, National Institute of Justice, 1985.

Guthmann, D., and Brenna, D. The Personal Experience Inventory: An

assessment of the instrument’s validity among a delinquent population in

Washington State. J Adolesc Chem Depend 1(2):15-24, 1990.

Hartstone, E., and Hansen, K.V. The violent juvenile offender: An empirical

portrait. In: Mathias, R.A.; DeMuro, P.; and Allinson, R.S., eds. Violent

Juvenile Offenders: An Anthology. San Francisco: National Council on

Crime and Delinquency, 1984. pp. 83-112.

Hawkins, J.D.; Lishner, D.M.; Catalano, R.F.; and Howard, M.O. Childhood

predictors of adolescent substance abuse: Toward an empirically grounded

theory. J Child Contemp Soc 8(1):11-48, 1986.

Hubbard, R.L.; Cavanaugh, E.R.; Craddock, S.G.; and Rachal, J.V. Outpatient

treatment for adolescent drug abuse. In: Friedman, A.S., and Beschner,

G.M., eds. Treatment Services for Adolescent Substance Abusers. National

Institute on Drug Abuse Treatment Research Monograph Series, DHHS

Pub. No. (ADM)85-1342. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1985.

Inciardi. J.A. The Drugs-Crime Connection. Beverly Hills, CA: Sage, 1981.

Jessor, R. Predicting time of onset of marijuana use: A developmental study of

high school youth. J Consult Clin Psychol 44(1):125-134, 1976.

Leukefeld, C.G., and Clayton, R.R. Drug abuse and delinquency: A study of

youths in treatment. In: Beschner, G.M., and Friedman, A.S., eds. Youth

Drug Abuse. Lexington, MA: D.C. Heath & Co., 1979. pp. 22-43.

Santo, Y.; Hooper, H.E.; Feldman, A.S.; and Conner, W. Criminal behavior of

adolescent non-heroin polydrug abusers in drug treatment programs.

Contemp Drug Prob 9(3):301-325, 1980.

Simonds, J.F., and Kashani, J. Drug abuse and criminal behavior in delinquent

boys committed to a training school. Am J Psychiatry 136(11):18-39, 1979.

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Winters, K.C., and Henly, G.A. Advances in the assessment of adolescent

chemical dependency: Development of a chemical use problem severity

scale. Psychol Addict Behav 1:146-153, 1987.

Winters, K.C., and Henly, G.A. Personal Experience Inventory (PEI): Manual.

Los Angeles: Western Psychological Services, 1989.

Wish, E.D. Drug testing. In: Crime File Study Guide. National Institute of

Justice. NCJ-104559. Washington, DC: U.S. Department of Justice, 1988.

AUTHOR

David Brenna, M.S.

Administrator for Special Projects

Division of Alcohol and Substance Abuse

Department of Social Health Services

OB21W

12th and Franklin Streets

Olympia, WA 98504-0095

109
Florida Department of Corrections’

Substance Abuse Programs

Wilson C. Bell, James G. Mitchell, Jennifer Bevino, Abbas

Darabi, and Richard Nimer

INTRODUCTION

The increased use and abuse of chemical substances within society. combined

with more effective law enforcement initiatives to address escalating criminal

behavior(s) associated with drug addiction, has focused attention on the

need for correctional systems to enact treatment programing. It IS no longer

acceptable for offenders to enter the correctional system with addiction

problems and be released without treatment opportunities being offered.

For many years, Florida, by virtue of its global location and extensive shoreline,

has been widely viewed as the principal importation point for the majority of

cocaine introduced into the United States. Contributing to this are the diverse

cultural population, rapid economic growth, and great mobility. The result has

been widespread abuse of crack cocaine, and this has greatly affected prison

admissions.

The Florida Department of Corrections has launched a significant effort

in the area of substance abuse treatment programing services designed

for members of the inmate population identified as having histories of

substance abuse and/or addiction problems. This programing effort

addresses the substance abuse treatment needs of identified members

of Florida’s inmate population through the use of a model encompassing

a comprehensive battery of substance abuse treatment services. The

program provides linkages between institutional and community resources

and has created new services with the support of Florida’s Governor and

Legislature.

BACKGROUND

In the early 1970s Law Enforcement Assistance Act (LEAA) funds allowed

the department to employ at least one drug counselor in each of its major

110
institutions. The LEAA also provided seed money for the development of

a 250-bed therapeutic community (TC) for young male offenders and a

20-bed TC program for female inmates. Unfortunately, even though the

percentage of inmates newly committed to the department who admitted

to drug problems increased at a steady rate to above 50 percent, various

financial shortfalls within State government and the collapse of the LEAA

funding source led to the general dissolution of the department’s drug

treatment program. However, the two TCs mentioned above and a strong

outpatient treatment program at one large youthful offender institution were

maintained.

In the intervening years prior to 1987, drug treatment primarily was in the

form of a close association with two community support groups, Alcoholics

Anonymous (AA) and Narcotics Anonymous (NA). Eventually, a skeleton

counseling staff began to emerge. It consisted of one or two professional

counselors principally assigned to the department’s mental health office,

but with ancillary duties involving coordinating or providing counseling

services for addicted inmates. In 1988 there were nearly 100 employees

whose duties included responsibility for drug counseling within Florida’s

correctional institutions. The prison population meanwhile had expanded

to about 46,000 in more than 50 major institutions (Florida Department of

Corrections 1988).

The recent increase in admissions to prisons in the State of Florida has been

primarily the result of drug offenders. These offenders accounted for 13

percent of the total admissions in fiscal year (FY) 1983-84 compared with 33

percent in FY 1990-91. With an inmate population of 46,233 at the end of FY

1990-91, up from 26,471 inmates 7 years earlier in FY 1983-84 (an increase

of 74.7 percent), the department has noted an alarming increase in the number

of drug and drug-related offenders entering the system (Florida Department of

Corrections 1991).

Data from FY 1990-91 (Florida Department of Corrections 1991) indicate that

the majority of drug offenders were incarcerated for possession of cocaine

(34.2 percent), sale of cocaine (43.5 percent), and trafficking in cocaine (9.4

percent). By comparison, the next largest category among specific drug

offender types was those convicted of selling marijuana (4.4 percent). Cocaine

offenders accounted for 87 percent of all drug offenders admitted to Florida

prisons in FY 1990-91. During FY 1990-91 one of three persons committed to

the Florida Department of Corrections was incarcerated directly as a result of

drugs. This ratio considered only the offender’s primary offense and did not

reflect those persons being incarcerated for property crimes committed to

support a drug habit. If these factors were computed into the equation, it is

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estimated that the percentage of drug-related admissions would approach 85

percent. In addition, the department’s data (Florida Department of Corrections

1989) indicate that the adult inmate population’s primary drug of choice is crack

cocaine, with alcohol running a close second. Youthful offenders’ drugs of

choice are alcohol and marijuana. It should be noted that the department’s

treatment efforts are geared toward chemical dependency/addictions and not

toward a drug of choice.

Probation and community control admissions for FY 1983-84 totaled 38,948,

with drug offenders accounting for 22 percent (8,667) of these admissions.

In FY 1990-91 total admissions for probation and community control were

77,844, and drug offenders accounted for 29 percent (22,598) of that total.

The most recent major trend in drug abuse is, by all accounts, attributable to

the appearance of crack cocaine (Florida Department of Law Enforcement

1990).

ASSESSMENT PROCEDURE AND THE TIER SYSTEM

Below is a summary of the comprehensive statewide Substance Abuse

Programs that includes an initial assessment phase and a Tier system

offering varying degrees of treatment for identified substance abusers

(Florida Department of Corrections 1990). The department is attempting

to provide the addicted offender with a continuum of care through the Tier

treatment programs. This continuum can result in the offender’s going

from Tier I to Tier IV in a process of successive and successful treatment

experiences. However, in many cases due to sentencing constraints,

offenders will experience only part(s) of the treatment continuum.

Although more than 50 percent of inmates admit to a serious problem with one

or more substances of abuse, it is clear that intensive therapy is not possible for

all. Therefore, an assessment procedure has been implemented at all reception

locations. Inmates sentenced to the Department of Corrections undergo an

assessment to determine the severity of their substance abuse addiction as

well as their readiness for treatment. Through the classification process, an

appropriate level of treatment is recommended.

Treatment programs provided within correctional facilities are identified by four

varying levels of intensity. In concept, inmates would enter the treatment

continuum at the appropriate level for their particular need. However, due to

a variety of factors, such as limited program space and denial (resistance to

treatment), initial placements may sometimes be at a lower level of intensity

than would be required individually. In such instances, one of the treatment

program objectives would be to encourage more intensive followup therapy.

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Each level of treatment in the Tier system has a finite timeframe, and each

focuses on clearcut objectives within those constraints.

Tier I

Tier I is a 40-hour program specifically designed to address the needs of

offenders who (1) have a less-than-severe substance abuse problem,

(2) are believed to have a severe problem but are denying the problem

exists and therefore are not considered ready for treatment, or (3) will

not have the opportunity to go through a longer program due to a very

short sentence. Although primarily designed to provide information as an

educational component, Tier I also introduces group counseling techniques.

In addition, and more importantly, ii serves as the beginning point to essential

followup treatment consisting of continuing group counseling; encouragement

to participate in AA, NA, and other support groups; and referral as appropriate

to a more intensive level of treatment. The Tier I program is provided either

by the department staff or through contractual arrangements with private

providers.

Tier II

Tier II is an intensive 8-week residential modified TC program housed within

a correctional institution designed for inmates with serious substance abuse

problems. This treatment level is aimed at those inmates who will not be in the

correctional system long enough to participate in a more extensive program.

Tier II also serves as a referral mechanism to other levels of treatment such as

long-term community-based treatment, referral to Tier III, and participation in AA

or NA. This Tier is characterized by frequent individual and group counseling.

Tier II consists of three phases. In Phase 1, Orientation, the stage is set for

effective participation in the recovery process. In Phase 2, Treatment, four

major learning themes are addressed: addiction education, life management,

skill building, and relapse prevention. Phase 3, Reentry, involves preparation

for reintegration into either the prison setting or the outside community or

some combination thereof. The process of closure with the treatment program

is completed. To meet program objectives without compromising security,

isolation from the greater institutional population is necessary to the most

practical extent possible. Tier II services are delivered by department staff

and contracted private providers.

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Drug Treatment Centers

Drug Treatment Centers (DTCs) are the newest component in the Department

of Corrections’ Substance Abuse Programs. This is a statewide system of

regional DTCs for treating minimum- and/or medium-custody inmates.

Emphasis is on those convicted of drug offenses, theft, or burglary and

those who have a cumulative sentence of 5 years or less. New inmates

assessed as being in need of drug treatment have a shortened reception

process and movement is made directly to the DTC in 3 to 7 days.

The entire DTC facility revolves around providing drug treatment services.

Inmates are involved in the TC process 24 hours a day, 7 days a week. The

format is an intensive 4- to 5-month treatment program using phases similar

to those of Tier II. A structured fitness regimen and nutritional training are

incorporated into the program. The physical training gradually builds fitness

and endurance while emphasizing personal discipline and self- and mutual-help

principles, building team/group cohesion, and improving mental alertness and

relaxation.

Tier III

Tier III is a full-service residential TC program. This treatment component is

6 to 12 months long and is currently provided in a female institution, a male

youthful offender institution, and an adult male institution. Additionally, the

department has contracts with community-based drug treatment programs

throughout the State to provide this service for eligible inmates approaching the

end of their sentences. These contract facilities are designated as Community

Tier III TCs. Currently, the department utilizes six such facilities throughout the

State and contracts for a total of 54 beds within those facilities. For placement

at such a facility an inmate must be classified as eligible for community work

release. As an inmate nears his or her release date, recommendations may be

forwarded to the Community Release Unit in the department’s Central Office for

an inmate to be placed at one of the Community Tier III facilities.

Description of Therapeutic Community Design

The Tier II, DTC, and Tier III programs are based on the TC model. The TC

treatment regimen uses self- and mutual-help approaches, peer pressure, and

role modeling in a structured environment to achieve the recovery goal. Peer

pressure is seen as the catalyst that converts criticism and personal insight into

positive change. High expectations and high commitment from both offenders

and staff support this positive change. TCs provide a 24-hour-a-day learning

experience in which individual changes in conduct, attitudes, and emotions are

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monitored and mutually reinforced in the daily regimen. TCs also offer a

systematic approach to achieve their main rehabilitative objective, which is

guided by an explicit perspective on the drug abuse disorder, the client, and

recovery.

The goals of a residential TC include producing a change in lifestyle, abstinence

from substance abuse, elimination of antisocial activity, increased employability,

and prosocial attitudes and values. The TC approach reinforces anticriminal

modeling, promotes the understanding of social vs. didactic learning, and

stresses the developmental process that occurs in a social learning context.

The TC approach to treating substance-abusing offenders has produced

positive research findings in the areas of outcomes, treatment retention, and

special populations (De Leon 1984; Hubbard et al. 1988).

Day or Night Treatment

A new concept within the department, this program provides a structured

schedule of treatment services that includes a minimum of 16 hours of activities

per week, 6 of which occur in individual, group, or family therapeutic sessions.

Services provided in this structured outpatient setting are consistent with the

services provided in the residential programs, except that the outpatient program

is conducted during the day, evening, or weekend hours to accommodate the

inmates’ institutional work schedule. Day or night treatment serves

approximately 40 inmates every 4 to 6 months and requires two contracted

counselors for staffing each program.

Tier IV

Tier IV is designed specifically to provide counseling services to inmates

assigned to Community Correctional Centers by means of contracted services.

This outpatient/aftercare treatment strategy focuses on relapse prevention

and supportive therapy. This 10-week program involves inmates during the

afternoon and/or evening prior to or after work and includes 8 weeks of

counseling, group attendance at AA or NA meetings, and educational groups.

During the final 2 weeks, inmates are prepared for community reentry. The

relapse prevention program is essential for this reentry process. Group,

individual, and family counseling sessions are held, and relapse prevention

plans are completed. Emphasis also is placed on developing and cementing

connections with community-based drug treatment programs, self-help support

groups, and other aftercare services.

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Substance-Abusing Offender Treatment Information Network

The Substance-Abusing Offender Treatment Information Network is not a

specified criminal justice or treatment program; rather, it is an information

system. The Network is a prescribed mechanism for transferring information

on drug offenders from one agency serving the drug-involved offender to

another so that a treatment intervention history can be developed. The goals

of the Network are (1) to channel information on drug treatment and other

drug interventions from one system component to the next, (2) to encourage

continuity of treatment and structured intervention with the drug-involved

offender, (3) to link all system components to ensure continuity of care, (4) to

define what action each unit will take to pass on intervention or treatment

information and what action will be taken once information is received, and

(5) to support research and evaluation on the effectiveness of offender

treatment. All criminal justice and treatment programs that provide specialized

services to the substance-abusing offender are participants of the Network.

Each program is encouraged to establish formal procedures that define how

the Network will be implemented in the respective agencies.

This information system is built on the premise that length of treatment with the

drug-involved offender correlates with a favorable treatment outcome (Hubbard

et al. 1988; Leukefeld and Tims 1988). The system is a structured method to

enhance the time an offender spends in treatment and to link components of

treatment in a systematic mode. Programs involved in the Network, in addition

to the Tier programs, include Treatment Alternatives to Street Crime (TASC),

jail treatment programs, postrelease supervision programs, community-based

treatment agencies, probation, parole, and community control. Brief

descriptions of these programs follow.

Treatment Alternatives to Street Crime. TASC programs provide screening,

assessment, treatment referral, and case management services. TASC staff

members serve as brokers to ensure that treatment placement is secured

and that progress in treatment is reported to the referring criminal justice

agency.

Jail Treatment Programs. Across the State, these programs provide

in-jail substance abuse education and treatment services. These services

are usually provided by local TASC or community treatment programs under

contract with the local county corrections authority. Offenders may be linked

with probation upon completion of their jail sentence. They may be referred

to TASC or to community treatment programs.

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Postrelease Supervision Programs. In FY 1990-91 more than 35,000

inmates were released from the Department of Corrections (Florida Department

of Corrections 1990). Upon completion of their sentences, offenders were

either released on parole or released under one of several programs that

provide for supervision once back in the community. These programs include

the following:

Provisional release. This program provides released offenders with

up to 90 days of supervision by a probation officer. Treatment can be

required as a condition of granting release.

Control release. This program operates like parole. The control release

agreement can require treatment and other performance conditions.

Conditional release. The parole commission controls access to this program

and can require involvement of up to 2 years. This program usually is used

for violent or sex offenders.

Community Correctional Centers (Tier IV). Offenders in this program are

still serving their sentences while living and working in the community. In

the Tier IV program, offenders are required to participate in specialized

treatment.

Community-Based Treatment Agencies. Florida has an established network

of community-based prevention and treatment agencies. These agencies

provide a variety of treatment modalities, including detoxification, methadone

treatment, short- and long-term residential programs, halfway houses, day

treatment, drug-free outpatient services, and support groups. The courts,

probation services, and institutions have a history of making referrals to these

programs. A recent survey of treatment agencies offering residential services

revealed that at least 50 percent of the clients being served had some form of

criminal justice involvement (Hubbard et al. 1988).

PROBATION AND PAROLE SERVICES

In the realm of Florida’s supervised population, substance abuse also

has increased. In FY 1988-89, a total of 34.3 percent of all offenders in

community supervision programs carried a primary offense in the category

of narcotic sales, manufacture, or possession. More significantly, 54.6 percent

of offenders on community supervision during that same period admitted their

involvement with substance use and abuse. Probation officers reported that

7 out of 10 offenders on their caseloads in FY 1990-91 have some degree of

problem with substance abuse, which amounts to 70 percent of the daily

population of 100,000 offenders supervised by Probation and Parole Services.

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It has become apparent to Florida lawmakers and the criminal justice

community that building more prisons cannot be the cure-all for this problem.

The focus is now on community-based alternative methods that impose a

range of sanctions to hold the substance-abusing offender accountable and

that serves to divert this population from limited prison beds. Strategies such

as front-end, early intervention and a well-defined system of Intermediate

sanctions seem to offer possible solutions.

Florida Probation and Parole Services launched a program in 1988 to address

the problem. Since that time, the program has continued to experience rapid

growth and is now considered to be a comprehensive effort that is an integral

component of the community-based supervision mission.

The major goal of the substance abuse programs continues to be the

identification, intervention, and affording of treatment opportunities when

warranted for offenders who have a substance abuse problem and addiction.

The major components of the program remain unchanged: staff training,

drug testing, and substance abuse treatment and evaluation through data

collection and analysis.

An intense effort has taken place in the past 2 years to develop mutual

strategies on how to deal effectively with the substance-abusing offender.

Much of that effort can be attributed to the Probation and Parole Services

drug specialist staff as well as community-based treatment providers assigned

to the courts who are responsible for educating and informing the major players

in the criminal justice system about drug testing and the continuum of treatment

services available.

In 1988 an initial appropriation of $500,000 was earmarked for the effort.

Program implementation was affected most significantly by the mandate,

providing that all offenders convicted of controlled substance violation would

receive random substance abuse testing intermittently throughout their term

of supervision. Thus, Probation and Parole Services was challenged with

designing and implementing a substance abuse program that was to focus

on two primary areas, testing and treatment.

State funding for substance abuse jumped to $2.1 million the second year,

which allowed further enhancements to the program. However, mandated

budget cuts reduced allocated funds by half. Sixty additional residential

treatment beds were brought online, helping to alleviate a critical shortage of

inpatient services available to offenders. In addition, five specialized staff

positions were established in each of the geographical regions of the State.

These regional drug specialists serve as coordinators and managers of an

expanding substance abuse program.

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During FY 1990-91 the program received an infusion of Federal block grant

funds to supplement State funds. Total funding for the program was $3 million.

This enabled the department to establish circuit drug specialists in each of

the 20 judicial circuits, which further localized and facilitated the day-to-day

operation of the substance abuse programs. Additional funds were provided

for more residential treatment beds as well as an increase in outpatient

services. It was no longer acceptable for a substance-abusing offender to

be placed on community supervision and not be afforded opportunities for

treatment to deal successfully with his or her substance abuse addiction.

During FY 1988-89 when the testing initiative began, 15,000 offenders were

drug tested. The statewide results presented a 33-percent positive rate. The

following year (FY 1989-90), the number of offenders tested had risen to nearly

50,000, with the positive rate dropping to 25 percent.

The most recent statewide data (FY 1990-91) show that more than 145,000

drug tests were administered to offenders. Although the number of tests

continued to rise, the positive rate decreased to 18 percent, its current level.

The department considers the program to be an unqualified success.

Countless line probation officers have detailed the significant change in

behavior demonstrated by some of the offenders who successfully completed

the various substance abuse programs. The successful completion rate of

offenders placed in nonresidential/outpatient programs was up 10 percent

over FY 1989-90. The successful completion rate for offenders sentenced to

residential treatment programs was 62.2 percent. This exceeds the rate of 50

percent for FY 1989-90. The overall success/completion rate of all treatment

programs exceeded 60 percent.

Because of the apparent success of both prison-based and community-based

treatment programs, the Governor and legislature made a commitment through

legislation and appropriations to radically increase the number of communitybased treatment beds for substance-abusing offenders. During the 1991

legislative session, the centerpiece of Florida Governor Lawton Chiles’

legislative package was a new initiative called the “Community Corrections

Partnership Act.” The Partnership Act has been designed to create additional

and more effective intermediate sanctions for an identified portion of the

offender population that could best be served and sanctioned in the community.

The thrust of this act binds the State and individual counties in an effort to

develop a range of credible interventions for this targeted group of offenders,

while allowing violent, more serious, or chronic offenders to remain in prison

for longer periods.

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This new legislation appropriated $150,000 as a grant award for the first year.

Additionally and more significantly, $4.2 million has been assigned to establish

570 nonsecure treatment beds for the drug offender. Startup funds also were

appropriated for the construction and operation of another 90-bed secure drug

facility, as well as a 256-bed work camp to divert offenders from incarceration

in State prisons. Part of this act also creates an additional supervision sanction,

Drug Offender Probation, that is designed to blend certain features of the

Community Control Program with regular probation. In this program, individual

offender drug treatment is emphasized, drug testing is mandatory, and reduced

caseloads of 50 offenders to 1 officer are utilized.

Florida has learned that along with Federal and State sanctions and funding

there is also oversight and accountability. This requires a reporting system

that is capable of producing timely, complete, and credible information. As

Probation and Parole Services substance abuse programs have continued

to expand, so has the volume of data that must be collected, analyzed, and

reported to various entities.

A new automated system is in place that allows capability for two vital functions.

First, offenders participating in substance abuse services can be tracked by

probation and parole. In conjunction with this, a treatment history is established

on the database for each offender, which is useful in individualized treatment

planning. Second, the system is capable of producing batch reports that

compile and format the data required by various funding entities. The system’s

ability to store information allows the department to conduct dispositional

studies, monitor program objectives, and review performance of contracted

treatment vendors.

During FY 1990-91 a total of 9,018 offenders were provided grant-funded

treatment services. In addition to this figure, a significant number of other

offenders received treatment through personal payment, county-funded

programs, and third-party insurance reimbursements. Noting that available

treatment resources in Florida are limited, additional offenders would have

been placed in treatment had additional funding and appropriate referral

sources been available.

These are exciting times of change and growth in the area of substance

abuse programing for Florida’s community supervision programs. Further

expansion of services is now on the horizon through the enactment of the

Community Corrections Partnership Act. This new challenge IS certain to

provide enhanced opportunities for the agency to continue its past success

in “making a difference” through effective substance abuse programing.

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DRUG ABUSE TREATMENT RESOURCE CENTER

The department also has implemented a Drug Abuse Treatment Resource

Center, which is responsible for the accumulation, distribution, and publication

of various materials regarding substance abuse for counseling staff and for

inmate use. A monthly newsletter is used to exchange innovative information

and to list new films, tapes, and publications. This creates a network for the

best use of resources.

RESEARCH

Treatment programs are only as effective as the evaluation of those

programs. Evaluation produces specific data without which any generalization,

revision, or improvement effort is guesswork and the results are not always

those intended. Evaluation is usually a process that is planned along with

initial program stages and continues long afler the program is implemented.

An effective evaluation produces an ongoing report on the program’s

implementation, operation, and accomplishment of its objectives.

Given this premise, the Florida Department of Corrections’ Substance Abuse

Programs recognizes three components of the evaluation of its drug abuse

treatment (Tier) programs: screening and assessment, process evaluation,

and outcome evaluation. The significance of these components’ interaction

also is recognized. Therefore, in its evaluation plan, the department has made

every effort to establish the proper professional settings for developing and

implementing these three components.

Screening and Assessment

The program’s main objectives are to identify substance abusers, to assess the

severity of their problems, to measure their readiness for treatment, and finally,

to recommend them to an appropriate treatment program. These objectives are

accomplished through inmate testing and interviewing at the time they enter

reception centers for classification.

The purpose of the screening is to identify substance abusers. Given the

number of inmates entering reception centers (more than 40,000 annually)

and the length of time they stay (usually 10 days) before being assigned to

other institutions, this identification must be done quickly to have time for

assessment. A Modified Addiction Severity Index (MASI) is used for this

purpose. This four-item test is administered to groups of inmates and scored

shortly after the session. Inmates scoring 3 to 8 on this test will automatically

become candidates for assessment.

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An indepth interview by a clinical social worker (CSW) is the major component

of the assessment procedure. During this interview, two assessment

instruments are used: the ASI and the Readiness for Treatment Scale. Other

factors considered in the assessment process include documented history of

substance use, referral or recommendation for treatment from other sources,

type of offense, and inmate’s request for treatment. Test results, combined with

the CSW’s overall knowledge of inmate status, determine the type of treatment

recommended for the inmate.

Process Evaluation

Process evaluation usually is conducted to establish and maintain program

integrity. It ensures that the program is implemented according to the intended

criteria and is achieving its objectives. Process evaluation consists of an

ongoing review of the program’s operational procedures, which are adjusted

according to evaluation outcomes. Procedures used in the process evaluation

include site visits, group meetings, training programs and workshops, data

collection and analysis, and program adjustments.

Outcome Evaluation

The department’s evaluation plan includes measuring the following indicators:

inmates’ participation and their rate of completion of the treatment program;

changes in inmates’ psychology, specifically their attitudes toward drug abuse;

inmates’ rate of recidivism; and employment stability. An improvement in any

one of these outcomes will be studied further for relationships to the treatment

provided through Tier programs.

It is to be noted that alcohol and other drug abuse is not used as an outcome

measure because the vast majority of inmates released from Florida prisons

either have no postrelease constraints or minimal day constraints. Thus, any

alcohol or other drug followup testing would require volunteers, and it is

believed that this would invalidate any research results since only those least

likely to relapse would voluntarily participate.

The following instruments are among those used in the outcome evaluation.

Knowledge Test (Tier I). Based on the content and objectives of Tier I,

a general knowledge test has been developed. Using a pretest-posttest

comparison, this test measures inmates’ knowledge about drugs and their

physiological and psychological effects. The results also can be compared

against test scores from a control group selected from the same population

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Psychological Measures (Tiers II-III). Inmates’ knowledge gain, although

encouraging, would not be sufficient to justify the resources allocated for

an elaborate treatment program. Considering the therapeutic approach of

the Tier programs and their anticipated effects on inmates’ personalities,

fundamental psychological changes are expected. These changes are

examined using the Brief Symptoms Inventory (BSI), which is given to all

incoming program participants and to all program graduates. The BSI is a

53-item test extracted from the SR-90 that was developed by Leonard R.

Derogatis, Director of the Division of Medical Psychology, Johns Hopkins

University. The BSI measures nine psychological indices: somatization,

obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety,

hostility, phobic anxiety, paranoid ideation, and psychoticism. The results

of the first round of BSI testing indicated significant improvement in these

indices for inmates who participated in treatment programs (Darabi 1991 a).

Followup Measures (Tiers I-IV). To collect demographic inmate information,

the Florida Department of Corrections’ database is used for followup studies.

Variables such as reincarceration are obtained and examined in light of the

inmates’ participation in and completion of the treatment programs. As a part

of ongoing evaluation of the programs, the initial recommitment study for Tier

programs was conducted in July 1991 (Darabi 1991 b). The results of this study

showed a significant reduction in recommitment rates for inmates who have

been through the Tier programs.

SUMMARY

The Florida Department of Corrections has worked diligently to plan and

implement a system of comprehensive institutional and community-based

programs. These programs strive to establish a functional, cost-effective

continuum of care for incarcerated individuals while providing necessary

linkages essential to transferring inmates back into society with the knowledge

and social skills necessary to lead a drug-free life. It is believed that a viable

working model has been developed that will offer inmate services and,

ultimately, afford them the opportunity and appropriate linkages to continue

treatment as needed after incarceration.

REFERENCES

Darabi, G.A. Psychological Impact of Tier Programs: An Outcome Evaluation.

Program Report. Florida Department of Corrections, Bureau of Planning,

Research and Statistics. Tallahassee, FL, March 1991a.

Darabi, G.A. Tier Programs Outcome Evaluation: A Recommitment Study.

Program Report. Florida Department of Corrections, Bureau of Planning,

Research and Statistics. Tallahassee, FL, July 1991b.

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318-269 0 - 92 - 5 QL3
De Leon, G., ed. The Therapeutic Community: Study of Effectiveness.

National Institute on Drug Abuse Treatment Research Monograph Series.

DHHS Pub. No. (ADM)85-1286. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1984.

Florida Department of Corrections. Annual Report. Tallahassee, FL, 1988.

Florida Department of Corrections. Probation and Parole Testing and

Treatment Update. Tallahassee, FL, 1990.

Florida Department of Corrections, Bureau of Planning, Research and

Statistics. Tallahassee, FL, 1991.

Florida Department of Corrections, Substance Abuse Programs. Inmate

Assessment Annual Report. Tallahassee, FL, 1989.

Florida Department of Law Enforcement. Crime in Florida: Uniform Crime

Report. 7989 Annual Report. Tallahassee, FL, January 1990.

Hubbard, R.L.; Collins, J.J.; Rachal, J.V.; and Cavanaugh, E.R. The criminal

justice client in drug abuse treatment. In: Leukefeld, C.G., and Tims, F.M.,

eds. Compulsory Treatment of Drug Abuse Research and Clinical Practice.

National Institute on Drug Abuse Research Monograph 86. DHHS Pub. No.

(ADM)89-1578. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988. pp. 57-80.

Leukefeld, C.G., and Tims, F.M., eds. Compulsory Treatment of Drug Abuse:

Research and Clinical Practice. National institute on Drug Abuse Research

Monograph 96. DHHS Pub. No. (ADM)89-1578. Washington, DC: Supt. of

Docs., US. Govt. Print. Off., 1988.

AUTHORS

Wilson C. Bell, M.E.D.

Assistant Secretary for Programs

James G. Mitchell, B.S.

Director

Adult Services Programs Office

Jennifer Bevino, M.A.

Director

Substance Abuse Programs

Abbas Darabi, Ph.D.

Research Associate

Bureau of Planning, Research and Statistics

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Richard Nimer, M.A.

Correctional Program Administrator

Probation and Parole Service

Florida Department of Corrections

2601 Blairstone Road

Tallahassee, FL 32399-2500

125
Comprehensive System Development

in Corrections for Drug-Abusing

Offenders: The Wisconsin Department

of Corrections

Gerald L. Vigdal and Donald W. Stadler

INTRODUCTION

One of the salient facts of the late 1980s has been the reemergence of public

awareness and concern over drug abuse and, in particular, its relationship to

crime. After more than a decade of neglect and attempts to deal with crime by

an ever-increasing rate of incarceration, a new consensus has developed that

the resolution of the crime problem in society is intertwined with the solution

to problems of drug abuse and addiction. The relationship between crime and

drugs has been well researched (Ball et al. 1983; Chaikin and Chaikin 1982;

Elliott and Huizinga 1984; Gandossy et al. 1980; Johnson et al. 1985, 1988;

McGlothlin et al. 1978), leaving little doubt regarding the association. Research

on arrestees with the Drug Use Forecasting system (Bureau of Justice

Assistance 1989) and on incarcerated offenders (Bureau of Justice Statistics

1988) clearly points to drug use at much higher rates compared to those of the

general public. It also has been documented that as an offender’s drug use

declines there is a concomitant reduction of criminal activity (Ball et al. 1987;

Nurco et al. 1985, 1989; Shaffer et al. 1987).

The impact of drug-related crime and the resultant societal frustration have

placed an overwhelming burden on the criminal justice system. Police, courts,

prisons, and probation caseloads have become clogged as drug offenders

are arrested, prosecuted, and sentenced to supervision or incarcerated in a

correctional facility. A variety of technological coping strategies have been

employed that earlier might have met with considerable resistance: widespread

urine testing, electronic monitoring of offenders, and various furlough and early

release programs. Along with the increase in correctional populations has

come a renewed interest in treatment. Research from the Drug Abuse

Reporting Program (Simpson and Sells 1982) and the Treatment Outcome

Prospective Study (Hubbard et al. 1989) provides strong evidence that

126
treatment can be effective with drug abusers. Studies of particular programs

or specific treatment modalities (De Leon 1984; McLellan et al. 1986) also

have documented success with drug-abusing offenders.

Even with these areas of demonstrated success, there is agreement within the

corrections profession that more needs to be done if the criminal justice system

is to survive. It is clear, for example, even to the most casual observer that

under current conditions offenders retain wide latitude to avoid treatment or

use treatment as a bargaining chip to evade responsibility for criminal behavior.

Due to these “cracks” in the system, there are substantial numbers of offenders

whose exposure to treatment has been largely superficial and clearly insufficient

to effect meaningful change. In addition to earlier identification, more effort is

required to place and retain offenders in treatment if the benefits of treatment

are to be realized (Bureau of Justice Assistance 1989).

To achieve these benefits a more systematic approach is required to meet

the challenges posed by the drug-taking offender. The National Drug Control

Strategies (Office of National Drug Control Policy 1989, 1990) have called for

an approach that incorporates various elements of treatment, prevention, and

supply and demand reduction. Critics have criticized the Federal plan primarily

on the basis of overemphasis on enforcement, but the overall strategy appears

sound. If an element is missing, it is the role that criminal justice, particularly

corrections, can play in focusing the overall effort. Correctional agencies are in

many ways ideally suited for developing a comprehensive approach that can

enhance the effectiveness of courts, police, and treatment providers. This is

particularly true of those correctional agencies that incorporate the functions

of incarceration along with probation and parole supervision within a single

administrative structure. The experience of the Wisconsin Department of

Corrections (DOC) in adopting a system-wide approach indicates the potential

of such systems.

THE WISCONSIN EXPERIENCE

Wisconsin’s specialized substance abuse programing began in 1975 with

the opening of a treatment unit for alcohol abusers. A 6-week, social skillsbased program was designed to treat these offenders just before release.

Emphasis was on alerting the parole agent to the offender’s participation

in the program and involving the agent in planning when possible. A final

assessment memo summarizing progress and problems was delivered

immediately upon completion of the program so that the agent could follow

through. Followup research comparing program admissions to an untreated

group of similarly selected offenders documented program effectiveness

(Vigdal et al. 1980).

127
Early in this program’s existence the positive response from parole agents led

to the establishment of an Alternative to Revocation (ATR) component that

remains today. The ATR component began when a parole officer proposed

placing an offender, whose supervision was being revoked because of a series

of alcohol-related violations, into the program. Recognizing that a successful

revocation would mean that this offender would have to spend longer than a

year in prison before receiving the needed social skills program, the agent

requested and received permission to place the offender in the prison program

and then return him directly to community supervision. Thus, considerable

prison time/bed savings were realized, the program was completed, and

the offender finished his community supervision. Recent data (D.W. Stadler,

personal communication, March 1990) on ATR placements show that

approximately 50 percent of offenders placed in ATR status complete the

program and return to community supervision. Currently, in spite of severe

overcrowding, 10 percent of treatment beds are reserved for ATR clients who

are unable to secure appropriate community treatment, and one-half of a 40-

bed minimum-security residential facility has been converted to an ATR center

specifically for the provision of substance abuse treatment to those offenders

facing revocation.

Success with the initial alcohol treatment program spurred development of two

other special treatment programs, which were created for inmates whose drug

of choice was primarily a drug other than alcohol. In 1981, for administrative

purposes, all three programs were consolidated into a single treatment center.

Today, the center is a 150-bed facility with 600 to 700 admissions annually;

each treatment program maintains a separate identity while serving a different

subpopulation of inmates. The original alcohol program was lengthened to 8

weeks but retained its focus on skills training and relapse prevention. A 9- to

12-month residential therapeutic community (TC) also was developed for

drug addicts that coupled traditional confrontation techniques with Yochelson

and Samenow’s theories on criminal thinking and the “criminal personality”

(Yochelson and Samenow 1975, 1977). The third drug program was added to

target younger, nondependent drug abusers with a more cognitively oriented

approach. Thus, a range of programing was offered that forced attention on

assessment procedures to match the needs of offenders to the treatment

programs. The desirability for assessment standardization quickly led to a

major effort to develop a unified substance abuse screening instrument.

THE SCREENING BATTERY

An early success involved the discrimination of treatment program

subpopulations on the easily administered self-report instruments of

alcohol dependence symptoms (the Alcohol Dependence Scale [ADS])

128
and involvement with other drugs (the Offender Drug Use History [ODUH]).

These instruments were dimensional-based and appeared to capture best the

distinction between those in need of the alcohol program and those in need of

the TC program. Differentiating the populations for the two drug programs

proved more difficult and grew more acute when it became necessary to assess

all needs at reception to the prison system. The solution was to expand the

battery to include other offender characteristics that research had shown to

be related to the treatment outcome of substance abusers (McLellan et al.

1983; Woody et al. 1985; Svanum and McAdoo 1989; Kosten et al. 1989).

The resulting multifaceted assessment battery is a marriage of dimensional

and categorical measurement approaches that utilizes both substance use

and abuse and other client features to rapidly identify offenders with similar

behavior and need profiles. Thus, clients can be assigned to the type of

substance abuse programing that most effectively addresses their problems,

which represents a commitment to the philosophy that treatment is more

effective when program content/techniques are most closely matched to client

characteristics (Glaser 1980).

The “matching” with this battery is achieved by assessing the offender on four

major dimensions: alcohol dependence, other drug involvement, psychiatric

impairment (Gawin and Kleber 1986; Khantzian and Treece 1985; Marsh et

al. 1988; Mirin et al. 1988; Rounsaville et al. 1985; Weiss et al. 1988), and

psychopathic tendencies (Gertsley et al. 1990; Woody et al. 1985). These

dimensions are viewed as a continuum, but cutting points were identified

through an iterative process of clinical experience, review of research on

assessment and treatment effectiveness, and field testing.

The battery currently includes four instruments to measure these critical

dimensions: the ADS, the ODUH, the Client Management Classification

Interview (CMC), and the Megargee offender typology derived from the

Minnesota Multiphasic Personality Inventory (MMPI).

Alcohol Dependence Scale

The ADS (Skinner and Horn 1984) is a 25-item, self-report instrument that

assesses the severity of alcohol dependence (Edwards and Gross 1976) as

defined in the World Health Organization’s International Classification of

Diseases-Release Nine (World Health Organization 1977). Items for the

ADS were culled from a longer parent instrument, the Alcohol Use Inventory

(Horn et al. 1977), which the Wisconsin DOC used in the developmental phase

of the battery. Research using the Alcohol Use Inventory (Berglund et al. 1988;

Skinner 1981; Wanberg and Horn 1985, 1987) and experience with that

instrument strongly support the ADS as the primary discriminator among clinical

129
populations (inpatient vs. outpatient; first admission vs. readmission). It was

determined that the ADS could be substituted without loss of significant

information (Lettieri et al. 1985).1

Offender Drug Use History

The ODUH (table 1) contains a brief substance abuse treatment history and

usage measures for 10 drugs or drug classes identified in the substance use

disorder section of the American Psychiatric Association’s Diagnostic and

Statistical Manual of Mental Disorders (Third Edition) (American Psychiatric

Association 1980). The same classes also appear in the 1987 revision

(Diagnostic and Statistical Manual of Mental Disorders: Third Edition-Revised)

(American Psychiatric Association 1987) under psychoactive substance

disorders. The drug scale is computed from the self-reported use of several

commonly abused illicit drugs and converted to represent one of three levels of

increasing involvement with other drugs (Donovan and Jessor 1983; Kessler et

al. 1976).

TABLE 1. Offender drug use history

Circle the letter that best describes your use of each drug.

1) You used nicotine (tobacco).

a) never.

b) a small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week but not daily.

e) daily.

2) You used alcohol (beer, wine, booze).

a) never.

b) small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week but not daily.

e) daily.

130
3) You used marijuana (pot, grass).

a) never.

b) a small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

4) You used amphetamines (speed, pep pills) without a prescription.

a) never.

b) small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

5) You used cocaine (coke).

a) never.

b) a small number of times (1-3) and stopped

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

6) You used barbiturates (downers, sleeping pills) without a prescription.

a) never.

b) small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

7) You used narcotics (heroin, codeine, morphine, Dilaudid) without a

prescription.

a) never.

b) small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

8) You used CHD (freak-out).

a) never.

b) small number of times (1-3) and stopped

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

131
9) You used LSD (acid), peyote, mescaline, or mushrooms

a) never.

b) small number of times (1-3) and stopped.

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

10) You used PCP (angel dust).

a) never.

b) small number of times (1-3) and stopped

c) no more than once a week.

d) more than once a week, but not daily.

e) daily.

Scoring Inmate Drug Use Scale

1) For items 3 (marijuana), 4 (amphetamines), 5 (cocaine), 6 (barbituates),

and 7 (narcotics) assign values as follows:

Response Value

2) Take the higher score from item 4 or 5 and sum it with the derived scores

from items 3, 6, and 7.

3) Record the total score on the line to right of letter S on the upper right of

page one.

NOTE: The raw score total should never be greater than eight.

Client Management Classification Interview

Assessing psychological impairment and psychopathic tendencies is

accomplished with a CMC interview (Lerner et al. 1986) or the MMPI offender

classification (Megargee and Bohn 1979), depending on resource availability.

The CMC is a semistructured interview with forced choices that categorize an

offender in one of five distinct areas requiring different methods of supervision

and treatment.

132
Megargee Offender Typology

The MMPI is a 566-item, self-report inventory that measures major dimensions

of psychopathology. Megargee’s system assigns the offender to 1 of 10 groups

through profile analysis of the 13 traditional MMPI scales. The almost parallel

development of both systems reflects the historical separation of institutions

from community corrections. The Megargee system was developed in an

institutional setting (a Federal prison) to meet institutional needs, whereas the

CMC originated as an instrument to guide probation and parole agents in the

use of different supervision strategies. Although the intention is to move toward

adoption of the CMC across DOC, this process is incomplete; therefore, both

assessments remain in the battery. However, the two methods are viewed as

sufficiently congruent for the purposes of the battery.

PROCEDURES

Procedurally, the need for substance abuse treatment is first determined

through ADS and ODUH scores. Those not in need of treatment may receive

educational approaches. Offenders needing treatment are further differentiated

either by the CMC or the MMPI into a subpopulation requiring either long-term,

intensive treatment or short-term treatment. Long-term treatment includes the

CMC limit setter (LS) or the three MMPI subtypes (Foxtrot, Able, and Delta).

These are seen as the functional equivalent of Yochelson and Samenow’s

“criminal personality” (1975, 1977). Prominent in the description of these

types is the lack of prosocial values and criminal lifestyles (i.e., psychopathic

tendencies). Typically, there is not only the absence of significant psychiatric

impairment but also what might be regarded as normal anxieties or concerns.

Treatment techniques for substance abusers without this clinical picture

generally have proven to be ineffective. Those identified by the ADS/ODUH

as needing substance abuse treatment can be assigned to a TC that provides

both the structure and the necessary confrontation to their criminal value

system. Finally, substance-abusing offenders who do not meet this profile are

differentiated, based on the salience of their alcohol dependence, and assigned

to separate programs, one primarily for alcohol-dependent offenders and

another for abusers of other drugs.

The procedure described above is intended to create a strong presumption as

to the best match between the offender’s substance abuse problems and the

program most likely to be beneficial. Special circumstances, however, may

abrogate such an assumption (e.g., LS offenders do not have a grant of

immunity to either psychiatric or organic problems, which makes placement in

a TC questionable). As such, the process IS a guide, not a replacement for

informed, sensitive, clinical decisionmaking.

133
TREATMENT METHODS

After providing treatment to drug abusers, it became evident that drug use

did not stop at the prison gate; rather, it was widespread and had to be

curtailed. Reports of such activity had circulated, but a urine testing program

begun on all intakes after the consolidation into a single treatment center

proved particularly revealing. Inmates arriving at the center from institutions

throughout the State were showing 25- to 30-percent positive rates. In 1984,

a receptive administration agreed to do a blind random sample across the

entire inmate population. Nearly 13 percent of all inmates were tested, with a

system-wide positive rate of 26.9 percent. Institutions ranged from as low as

14 percent to as high as 43 percent. Once baseline data had been collected,

a system-wide urinalysis program was implemented, and the rate of positive

urines has been reduced to less than 4 percent (Vigdal and Stadler 1989).

Drug Education

In a further effort to reduce demand beyond treatment and urine testing, drug

education courses have been offered at three major institutions over the past

several years for those who are assessed as having either no or minimal

substance abuse treatment needs. The DOC is revising and broadening the

scope of these services. Drug education soon will be offered to every inmate at

both reception and release. Drug education at reception will focus on selfassessment of how drugs have caused difficulties in the inmates’ lives, what

they can do about it while incarcerated, and the necessity for a drug-free prison

environment. The drug education for all offenders being released will focus on

relapse prevention, services offered in home communities, and the importance

of relationships with parole agents.

Female Offenders

The treatment of drug-abusing female offenders has presented unique

difficulties. Attempts to adopt the male-oriented programs described above

proved both ineffective and problematic. Placements in a community-operated

TC, after legislative changes made it possible, were met with dropouts and

failures. Programing coeducationally with male inmates at the treatment

center on a day basis was equally unsuccessful. In 1985, a program was

initiated at the women’s prison, which departed from prior treatment efforts by

using a feminist model, based on empowerment and consciousness-raising

and focused on women’s issues. In 1988, a similar program was established

under a Bureau of Justice Assistance grant (87-DD-CX-0008) at a minimum

security facility for female offenders. This program is being evaluated as one

of six model State programs.

134
Continuity of Care

A comprehensive system requires continuity of care with a majority of inmates

involved in treatment just before release. However, the absence of meaningful

community drug abuse treatment has been a tremendous liability. Generally,

lacking funds to purchase services and encountering a treatment model to

which they cannot relate, many offenders find themselves without treatment

even when they are willing to accept it. The parole agent often has been the

single link the offender has to the treatment system. However, access to

continuing community care has been impeded by lack of training for prison

personnel in supervising and treating drug-abusing offenders as well as by

limited funding. In the past, agents could confer with treatment staff and the

inmate to develop preparole plans or make contact by telephone; but without

training and resources, these efforts often were “paper” exercises. With the

recent availability of the “war on drugs” money, corrections in Wisconsin moved

decisively to address both areas of weakness and enhance continuity of care.

Intensive Supervision Specialists

In April 1988, 10 Intensive Supervision Program (ISP) positions were

authorized to supervise the most serious drug offenders. These specialists

began operating in teams of two with a combined caseload of 40. Supervision

standards were developed to hold probationers accountable for their drug use,

either through a series of escalating sanctions or to ensure the delivery of

treatment services. Contacts were made as often as necessary with the

assurance of two contacts per week. Urinalysis was done twice per week to

avoid continued use while on intensive supervision. Initial data indicate that

even within this serious drug-using population, drug use is declining.

Year-end data for 1989 (Wisconsin Correctional Service, unpublished data, May

1990) in the Milwaukee metropolitan area showed that 25.3 percent of new

probationers tested positive, whereas only 12.8 percent of ISP clients were

positive. Since its inception, five additional ISP drug agents have been added.

Day Treatment

To develop programs that are compatible with institutional programs and

specifically designed for offenders, the DOC opened its first full-time day

treatment program in early 1988. Day treatment is a 90-day program,

contracted to a nonprofit corporation with previous experience working with

offenders. This program was modeled after institutional programs with a dual

focus on drug use and criminal thinking. Monitored by local probation and

parole staff who are immediately involved in its direction, this program has

135
become a catalyst for community action. The program recently provided

training for the entire staff onsite at a minimum security prison on drug abuse

and criminal thinking. That minimum facility now serves both as an aftercare

facility for inmates who have completed the institution program but are not yet

released and as a pretreatment facility for offenders who are to enter day

treatment after release.

Since the establishment of the first day treatment program, 12 others have

been created. Each program will operate with a similar model and eventually

will coordinate activities with a minimum security facility in its area. One facility

is devoted to female offenders. This model will create the final step in “closing

the loop” with drug-abusing offenders. If an offender is using drugs in the

area where this coordinated approach is in place, a referral can be made to a

community-operated, corrections-based treatment program. If failure occurs

or offenses continue and the client is incarcerated, continued institutional

programing is assigned. If the inmate refuses treatment while incarcerated,

treatment is mandated upon release after placement in the minimum security

facility where treatment then begins. Other release options include 15 halfway

houses, also under contract for offender treatment; the majority are directed at

drug abusers. Currently, there are four facilities for females and two exclusively

for Native Americans. To ensure communication and continuity across the

system, joint meetings are held between ISP agents and institutional treatment

staff and day treatment providers and institutional treatment staff.

As additional funding is secured, more components are being added to

the system. A bill passed in a special session of the Wisconsin State

Legislature in December 1989 not only funded the new day treatment

programs described above but also funded, as of July 1, 1990, an expansion

of the original women’s program, a shock incarceration program for young

offenders, a 50-bed preprogram in medium security for inmates entering the

TC, and a 50-bed unit for low-functioning offenders. The same bill supported

electronic monitoring for offenders in the community who repeatedly test

positive for drugs and the initial implementation of the assessment process for

all new probationers upon reception from the courts-the first step in making

the assessment process uniform across the entire DOC.

FUTURE PLANS

Future plans include full implementation of the assessment process across

DOC, the development of an aftercare specialist in each day treatment program

to conduct support groups and assist in social service needs, evening/weekend

treatment for offenders who relapse and are employed, and additional and

enlarged programing to selected initiatives as appropriate based on needs.

136
As these elements are put in place, DOC’s substance abuse treatment

programing will continue to take on most of the four features identified by

Giuliani and Schnoll (1985) as being characteristic of a comprehensive

treatment system: (1) uniform assessment (centralized for institutions),

(2) focus on relevant patient characteristics beyond substance severity,

(3) treatment modalities that are applied differentially, and (4) different levels

of care or intensity of treatment. Up to now, most of the progress has been

made on the first three features; more emphasis is needed to address treatment

intensity. Greater sophistication will develop in addressing other areas related

to treatment outcome (Fowles 1988; Meek et al. 1989; Skinner et al. 1984). In

so doing, DOC will be more effective in addressing the needs of offenders and

thereby better contributing to the solution of these problems of crime and drug

abuse.

NOTE

1. Copies may be obtained from the Addiction Research Foundation, Marketing

Services, Department 417, 33 Russell Street, Toronto, Ontario M5S 2Sl

CANADA.

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1982.

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treatment for alcoholism and drug addiction. Br J Psychiatry 138:312-380,

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AUTHORS

Gerald L. Vigdal, B.C.D

Director

Donald W. Stadler, B.A.

Psychological Services Associate

Office of Drug Programs

Wisconsin Department of Corrections

One West Wilson Street

Madison, WI 53707

141
Oregon Prison Drug Treatment

Programs

Gary Field

INTRODUCTION

Oregon has more than a decade of experience providing innovative drug

treatment services to inmates. In 1975 the Oregon Legislature authorized

an increase in beer and wine taxes and dedicated part of those tax receipts

to create what became known as the Cornerstone program. Located on the

grounds of Oregon State Hospital, Cornerstone is a 32-bed therapeutic

community (TC) program for alcohol- and drug-abusing inmates. In 1977,

the Corrections Department began funding what has become known as the

Correctional Institution Treatmen! Services (CITS). The CITS program consists

of contracts with community treatment professionals and agencies to come into

the institutions to provide alcohol, other drug, and mental health services to

inmates on a part-time basis.

The Oregon Legislature provided funding for three additional residential

treatment programs for inmates that began in 1979. These programs also

operate as TC models and are located on the grounds of the State hospital:

the Sex Offender program, the Mentally or Emotionally Disabled program, and

the Social Skills program (for mentally or socially retarded inmates). Each of

these programs includes specific drug treatment components. To facilitate

coordination among the mental health, alcohol, and drug agencies and the

corrections agencies, the legislature created the Mental Health in Corrections

Policy Board to oversee the programs, all of which were combined to form the

Correctional Treatment Programs in 1979.

In 1988 Oregon received a grant from the Bureau of Justice Assistance (BJA)

to develop a comprehensive plan to improve and develop drug services for

inmates. The creation of this comprehensive plan has been accompanied by

recent rapid growth in Oregon prison drug treatment programs.

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CURRENT PROGRAMS

Cornerstone

Cornerstone is the most intensive substance abuse treatment program available

for Oregon inmates. Most Cornerstone residents have long criminal histories.

The primary objective of Cornerstone is to intervene with chronic addicts with

long criminal histories to significantly reduce their rate of crime. Cornerstone

serves about 80 people per year.

Correctional Residential Treatment (CORT) Programs

The 50-bed Powder River Alcohol and Drug Program began accepting inmates

in February 1990. Based roughly on the Cornerstone model, this program

serves younger inmates with less recidivistic criminal histories. A second

program with 100 beds, half of which will be for female inmates, opened at

the Columbia River Correctional Center in Portland in November 1990. The

primary objective of CORT is to reduce the rate of criminal recidivism among

addicted offenders. These programs began serving about 450 inmates per

year in 1991.

CITS Counsellng

The CITS program consists of part-time contracts with community treatment

professionals and agencies to provide once-per-week group counseling.

Culture-specific services are offered to black, Hispanic, and Native American

inmates. The primary objective of CITS counseling is to help inmates begin to

develop a sense of responsibility for their behavior by accepting and learning to

manage their addiction. CITS counseling currently has 222 slots and serves

about 444 people per year.

CITS Cooperative Agreements: State Alcohol and Drug Slots

Agencies in Marion and Multnomah Counties (Salem and Portland) are using

a few State-funded community drug treatment slots to begin seeing individuals

in prison settings who will be returning shortly to those communities. These

services are much like CITS counseling services except they add the element

of continuity once the offender leaves prison. The primary objective is to begin

counseling services before the offender paroles and to continue services during

parole to reduce relapse and recidivism. Cooperative agreement programs

have 20 slots, serving 60 offenders per year.

143
CITS Cooperative Agreements: Corrections Release Subsidy

The Department of Corrections is piloting a program of CITS cooperative

agreements with release subsidy funds for individuals who are a poor risk to

make use of subsidy money for housing and food (e.g., people who are likely

to sublet their housing to purchase drugs). The operation and the primary

objective of this program are the same as those outlined in the previous section.

This program has 55 slots and is serving about 165 offenders per year.

Parole Transition Demonstratlon Project (Washington County)

The Parole Transition Demonstration Project (PTDP) builds on the cooperative

agreement concept. Federal grant funds are being used on a pilot basis to

answer the following question: “What is the effectiveness of providing a tightly

coordinated, thorough transition service for addicted inmates?” The hypothesis

is that this service will reduce criminal recidivism by maintaining these people in

community alcohol and drug programs. This program has 60 slots and serves

about 100 people per year.

Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)

The fellowships of AA and NA are perhaps the most effective self-help

organizations in the world. Many addicts and alcoholics have begun or

continued their recovery because of what they received at the fellowships

About 350 inmates per week attend institution AA or NA group meetings.

Alcohol and Drug Education Classes

These classes are offered in the institutions through Chemeketa Community

College in Salem and Blue Mountain Community College in Pendleton. The

classes typically meet once per week for 3 months. The primary objectives are

to educate alcoholics and other addicts about their disorder and to provide a

secondary prevention service for substance abusers. There are currently 185

education slots serving 740 people per year.

Information Centers

Located in all institutions, these centers provide books, brochures, films, and a

self-exploration manual. The primary objective is to be a broad-based, frontline

intervention to steer substance-abusing and addicted inmates toward the ladder

of recovery services identified above.

144
The Cornerstone and the CORT programs actively recruit recovering addicts

and offenders as program staff to serve as positive role models. All staff

members must have a specified number of years of drug- and crime-free

community living to be considered for employment. College degrees are not

required for entry-level employment at these programs, but as a matter of

practice, all new hires have prior relevant experience to prepare them for this

difficult work. CITS program staff are independent contractors who are selected

on the basis of their training and experience in delivering outpatient drug

treatment services to offenders.

A 9- to 10-percent sample of all Oregon inmates are subject to random

urinalysis testing monthly. Each inmate in the intensive programs receives

urinalysis testing once to twice per week on a random basis. A positive

urinalysis by one of these program participants results in immediate removal

from the program. However, the individual may reapply after 2 weeks, and

he or she usually is allowed to return to the program shortly after completing

a writing assignment. This immediate sanction has led to a positive test rate

of a small fraction of 1 percent from the addicted offenders in treatment. All

positive tests are confirmed by a separate urinalysis technology.

The Oregon Department of Corrections is attempting to organize these services

into a balanced service system wherein a coordinated range of services is

available, varying in intensity, to match the service needs of the population.

CORNERSTONE: PROGRAM DESCRIPTION

Program Population

Prospective clients are referred to Cornerstone by prison counselors.

Admission criteria require that each candidate has an extensive history of

alcohol or other drug abuse, is willing to make a commitment for at least 6

months of community followup treatment after release from the residential

part of the program, has not less than 6 nor more than 18 months before

parole date, and is granted minimum security status by the prison institution

superintendent. The program also tends to deny admission to candidates who

have a history of psychosis or sex offenses because the State provides other

specialized programs for these populations. Most referrals who meet the basic

criteria are admitted to the program. Referrals to Cornerstone usually have

histories of chronic substance abuse and chronic criminal behavior. Table 1

highlights some of the critical demographic characteristics of the Cornerstone

treatment population in 1984. The mean number of adult felony convictions, the

mean total time incarcerated as an adult, and the age of first substance abuse

document the extreme chronicity of this group of inmates.

145
TABLE 1. Characteristics of the Cornerstone treatment population given in

group means

Characteristic Group Mean

Age 31.0

Age at time of first arrest 13.6

Number of adult arrests 13.7

Number of adult felony convictions 6.9

Total time incarcerated as an adult 7 years, 7 months

Age at time of first substance abuse 12.5

Treatment Program

Cornerstone is a modified TC with a varied schedule of groups and classes.

Residents at Cornerstone give and receive strong and honest feedback to

assist with self-examination of destructive, irresponsible behavior and lifestyles.

They are regularly tested for alcohol and other drug use. Threats or acts of

violence, use or possession of drugs or alcohol, or sexual behavior result in an

inmate’s immediate return to prison. Demonstrated lack of responsibility or

personal commitment leads to consequences-determined by the treatment

community (staff and residents)-that are designed to aid the treatment

process.

Treatment at Cornerstone occurs in four phases, with roughly half the time

spent in the two inpatient phases and half in the two transition phases.

Treatment addresses the three interlocking issues of addiction, criminality,

and institutionalization (Warren, unpublished manuscript).

Orientation Phase. In the orientation phase, lasting approximately 30

days, residents have a highly structured schedule of classes and activities.

The classes are designed to teach the skills and concepts needed to most

effectively use their time in treatment and to relax the rigid defenses that were

necessary for survival in prison. Classes include assertiveness training, selftalk, group membership skills, values clarification, and wellness. Residents

begin AA/NA 12-step work and attend onunit self-help group meetings during

the orientation phase.

Intensive Phase. During the next 4 to 8 months, the resident enters the

intensive inpatient phase of treatment. With an increase in privileges comes

an increase in accountability. Residents begin to see how their criminality and

146
their substance abuse are mutually interdependent. There are classes in

criminal thinking and criminal cycles or patterns. Cognitive and behavioral

interventions are designed and practiced.

Residents learn the value of a commitment to honesty, responsibility, and selfdiscipline within a caring and supportive environment in which a peer is as

likely to insist on accountability as an authority figure. An elected resident

council is responsible for the day-to-day business of the community, including

identifying and addressing “problem” issues, attitudes, or resident behaviors.

This responsibility allows residents to try on new roles and breaks down the

traditional “we-they” attitude that supports a criminal value system. Clients in

this phase focus on all personality characteristics, skill deficits, relationships,

or attitudes that present a barrier to recovery. They participate in groups and

classes using writing assignments, reading, role-play, video, art, music, or any

other available medium to break down defenses and consolidate learning.

Residents write their own treatment contracts (plans), with the assistance of

their primary counselor and approval by the treatment team. During this phase,

8- to 12-week classes include Anger Management, Human Sexuality, Parenting,

Living Skills, and Relapse Prevention.

Roughly halfway through the intensive inpatient phase, residents begin

attending two weekly community 12-step meetings. They are encouraged to

find and use a sponsor and to attend recreational activities with other recovering

people. Once the recovery support system is in place, residents may take

passes with family members who have been attending family group or with

each other. Thus begins the process of transition to community living and the

application of skills learned in treatment to the outside community.

Transition Phase. After some initial personal preparation time in transition,

residents complete 40 to 80 hours of community volunteer work. They then

seek and begin community employment while continuing groups and classes

at Cornerstone and regular community 12-step participation. The Cornerstone

groups during this time focus on stress management, relationship building, adult

children of alcoholics issues, and recovery planning. Substantial effort is put

into counseling and support around the many real-life issues that arise during

transition. The Cornerstone work-skills trainer assists with employment issues,

including job searches and job adjustment. The transition staff personnel, who

also work with family members throughout the treatment phase, assist them in

this phase with family adjustment issues.

As parole nears and the resident achieves treatment and support system

stability, the resident seeks an apartment, and his or her pass time is gradually

147
increased. Since new recovery-focused habit patterns still have a primarily

institutional context at this point, this is the most difficult and most important

time in treatment. As residents encounter real-life problems and practice

productive coping skills, many need at least one period of reimmersion in the

program before being paroled. This helps the resident to refocus on relapse

signs, redesign interventions, and start again with an improved base of

experience.

Aftercare Phase. The fourth phase of treatment at Cornerstone is aftercare.

For those being paroled to a distant community, aftercare is arranged with a

local treatment provider. Transition staff members assist the resident by

meeting with the local provider, parole officer, family members, and the new

AA/NA sponsor to establish an effective recovery plan. If paroling locally, the

client continues weekly group and one-to-one counseling, spends time on the

Cornerstone unit giving and receiving peer support, and meets regularly with

other Cornerstone graduates. Residents become provisional members of the

Cornerstone Alumni Association when they begin their transition and become

full members upon completing parole.

Research Results-Cornerstone Program1

In an earlier study (Field 1985) Cornerstone clients showed, as a function

of the treatment program, enhanced self-esteem, reduced psychiatric

symptomology, increased knowledge in critical treatment areas, reduced

criminal activity, and reduced criminal recidivism. In a 1989 study (Field

1989), the Law Enforcement Data System (LEDS) was used to take a closer

look at the effect of the program on criminal activity. LEDS is a computerized

telecommunications and information system for Oregon law enforcement

agencies that lists criminal activity for Oregon and accesses the Federal

criminal justice data system.

The 220 unduplicated program discharges from January 1, 1983, through

December 31, 1985, were sorted into four experimental groups: program

graduates (Graduates) (n=43); nongraduates (NG) who spent more than 6

months in the program (NG>6 months) (n=43); nongraduates who spent more

than 2 but less than 6 months in the program (NG 2-6 months) (n=58); and

nongraduates who spent between 1 day and 2 months in the program (NG 0-2

months) (n=65). Six members of the potential NG 2-6 month group had to be

eliminated from the study because four were deceased and two had failed to

be released from prison since leaving the program. Five potential NG 0-2

month group members had to be eliminated because they were in the program

so short a time (less than 1 day) that adequate identifying information had not

been collected by program staff. The remaining 209 subjects were distributed

throughout the four experimental groups as noted above.

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The dependent variables in this study were arrests, convictions, and prison

incarcerations. Arrests were tabulated as ‘arrest events” as reported in LEDS.

These “arrest events” may have included multiple arrest “counts” at the time

of arrest. Similarly, convictions were tabulated on the basis of each “arrest

event” and did not consider convictions on multiple “counts.” Therefore, only

one tabulated conviction was possible for each “arrest event.” Arrests and

convictions included all recorded arrests and convictions-misdemeanors as

well as felonies. County jail time spent (as opposed to suspended sentences)

that exceeded 6 months (more than 179 days) on one conviction was counted

as equivalent to a State prison incarceration. County jail time of less than 6

months duration along with fines and probation was considered as a conviction

without prison incarceration.

In the first part of the study, absences of any arrests, convictions, and prison

time for 3 years after the beginning of parole were compared across all four

experimental groups.

in the second part of the study, rates of arrest, conviction, and prison

incarceration were compared across the groups for a “3-year” interval after

parole and for two “3-year” intervals before incarceration for the offense that

led them to the Cornerstone program. The 3-year intervals are “36-month atrisk intervals” because each of these periods included a complete 36 months

without incarceration time. So if, for example, after 12 months into an interval,

an individual was incarcerated for 4 months, the interval would be extended for

4 months (from 36 to 40). This method creates a full 36-month at-risk time

interval of study and is a more accurate measure of frequency of criminal

activity.

Results and Discussion

Table 2 presents absence of arrests, convictions, and prison incarcerations for

3 years after parole for Cornerstone graduates (average stay of 11 months),

nongraduates who stayed in the program for more than 6 months (180 days),

nongraduates who stayed 2 to 6 months (60 to 179 days), and nongraduates

who stayed less than 60 days.

The order of success as measured by no arrests, convictions, or prison

incarcerations in table 2 consistently favors time in treatment. Program

graduates consistently do much better than nongraduate groups, even

though many graduates continue to have some contact with the criminal

justice system. The two “partial treatment” groups (2-to 6-month and more

than 6-month groups) show results that are similar to one another but, again,

consistently favor time in treatment. The less-than-60-day group comes close

149
TABLE 2. Rates of avoiding any arrest, conviction, or prison time for 3 years

after parole for Corners tone participants from 7983 through 1985

(percent)

No No No

Arrests Convictions Prison Time

Graduates

(n=43)

37 51 74

Nongraduates who completed

at least 6 months (NG>6 mo.)

(n=43)

2 1 28 37

Nongraduates who completed

2 through 5 months (NG 2-6 mo.)

(n=58)

12 24 33

Nongraduates who left before

60 days (NG 0-2 mo.)

(n=65)

8 11 15

to being a no-treatment comparison group. The poor results shown by this

group without significant treatment are noteworthy

The consistent ordering of success rates and the constancy of relative

success among the groups across arrest, conviction, and prison incarceration

data suggest that any of these three dependent variables is an equally usable

outcome measure.

Because simple presence of absence of arrests, convictions, or prison

incarcerations over a lengthy period hides much of the criminal activity that is

occurring, it was decided to measure rates of each of these outcome variables.

By comparing posttreatment rates with pretreatment rates, it was hoped that a

clearer picture of the effects of intensive treatment would be gained.

Figure 1 presents arrest rates for the four experimental groups over

pretreatment and posttreatment 3-year at-risk intervals. Figures 2 and 3

present the same data for convictions and prison incarcerations. The data

presented in all three figures are remarkably similar. In each case

the four experimental groups are virtually identical at the pretreatment intervals.

150
FIGURE 1. Group mean arrest rates overpretreatment and posttreatment

3-year at-risk intervals (NG=nongraduates)

FIGURE 2. Group mean conviction rates over pretreatment and

posttreatment 3-year at-risk intervals (NG=nongraduates)

151
FIGURE 3. Group mean incarceration rates over pretreatment and

posttreatment 3-year at-risk intervals (NG=nongraduates)

In each case, all four groups show accelerating criminal activity across the

pretreatment intervals. Also in each case, the relatively untreated group (NG

0-2 month) shows a continuation of accelerating criminal activity following their

brief exposure to intensive treatment. Finally, in each case, the treated groups

show a decrease in criminal activity that correlates positively with time in

treatment. As in the first part of the study, program graduates do significantly

better than nongraduates.

These results present a more thorough and graphic display of the effects of

intensive treatment on reducing criminal recidivism among addicted offenders

than is possible from the data in table 2.

This study has two limitations. First, subject motivation for change is not

controlled for across the experimental groups. Some of the positive effects

may have occurred because those inmates who stayed in treatment were

more motivated rather than the results being due to specific treatment effects.

There are two counterbalances to this study limitation: (1) Subject motivation

at some point is always a part of successful treatment and (2) no motivational

differences between the groups are apparent in the pretreatment data in figures

1,2, or 3.

Second, the complexity and requirements of measuring pretreatment and

posttreatment arrest, conviction, and prison incarceration rates necessitated

that significant numbers of subjects in some of the groups be dropped from

152
part of the study. The question is, What biasing factor occurred by dropping

those subjects from the second part of the study? That question cannot be

answered with any certainty at this time. However, the subjects who were

dropped from the nongraduate groups were dropped largely because they had

recidivated at such a rate that they had not yet achieved 12 full months of

community time in the 3 to 5 years since their parole. These individuals,

therefore, probably represent the “worst cases” in the nongraduate groups and

would likely push the arrest, conviction, and incarceration rates at posttreatment

even further apart, creating even more separation between the experimental

groups.

CONCLUSIONS

The following conclusions are drawn from the results of this study:

1.

2.

3.

4.

5.

The Cornerstone program continues to demonstrate a positive effect on

decreasing the criminal activity of program participants.

Addicted offenders who receive little or no treatment show an accelerating

pattern of criminal activity over time.

Time in treatment in an intensive treatment program. for addicted offenders

correlates positively with measured decreases in criminal activity.

Many successfully treated addicted recidivist offenders continue to show at

least some involvement with the criminal justice system after treatment,

even though their involvement is reduced.

Arrests, convictions, or prison incarcerations all seem to be approximately

equally accurate measures of criminal activity.

COMMUNITY REENTRY EFFORTS

Community reentry is a critical component of all of Oregon’s prison-based

programs. Cornerstone has an active aftercare phase that continues at least

6 months into the individual’s parole. The new CORT programs have funds to

purchase service in their clients’ home community as part of each aftercare

plan. The State-local cooperative agreement programs involve close and

contractual working agreements between the institution release center and the

local drug treatment providers.

However, the vanguard of community reentry programing for drug-involved

offenders in Oregon is the PTDP in Washington County (suburban west

153
Portland). This project is funded with BJA grant funds. The essential

ingredients of the program are as follows:

1.

2.

3.

4.

5.

Service providers “reach in” to the institution. Drug treatment services

begin while the individual is still incarcerated, usually several months

before parole. Washington County inmates have their own group run

by county drug treatment providers.

Joint institution-community release planning. Release center staff develop

the inmates’ release plan cooperatively with the inmate and the project

coordinator. Inmates are included in the planning process, and they sign

an agreement of program participation that includes a listing of graduated

program incentives and sanctions.

Intensive supervision. Once the drug-involved offender paroles, he or she

is placed on an intensive supervision caseload.

Continuity of treatment. Group treatment continues into the community,

usually with the same group leader and with many of the same members

of the individual’s institution group. Peer support for abstinence and

recovery is an important theme of these groups.

Careful management of incentives and sanctions. Throughout the

process, offenders are provided with incentives for program participation

and sanctions for noncompliance or relapse. In the release center,

participating inmates are given desirable housing (as a group), may

earn extra pass time, are provided with special job skills counseling,

and are given special consideration for release subsidy funding. They are

monitored more closely, including urinalysis, and lose privileges according

to a graduated schedule. In the community, program participants also are

monitored more closely, experience graduated sanctions, and have the

incentives of housing, employment, and other specialized services.

NOTE

1. The studies described in this section have been completed on the

Cornerstone program. Similar studies are under way for the new

programs described in the preceding Current Programs section.

REFERENCES

Field, G. The Cornerstone program: A client outcome study. Fed Prob 49:50-

55, 1985.

154
Field, G. The effects of intensive treatment on reducing the criminal recidivism

of addicted offenders. Fed Prob 63:51-56, 1989.

Warren, G. “Cornerstone Drug and Alcohol Treatment Program. Oregon

Correctional Treatment Programs.” Unpublished manuscript, 1989.

AUTHOR

Gary Field, Ph.D.

Manager

Alcohol and Drug Services

Oregon Department of Corrections

2575 Center Street, N.E.

Salem, OR 97310

155

318-269 0 - 92 - 6 QL3
Outcome Evaluation of a Prison

Therapeutic Community for Substance

Abuse Treatment*

Harry K. Wexler, Gregory P. Falkin, Douglas S. Lipton, and

Andrew B. Rosenblum

INTRODUCTION

A summary of the extensive research on the relationship between drug abuse

and crime (Gropper 1985, based on the work of Johnson et al. 1985; Ball et al.

1983; lnciardi 1979) provides convincing evidence that relatively few severe

substance abusers are responsible for an extraordinary amount of crime. The

need for effective prison-based drug treatment is obvious; however, the difficult

problem is to provide treatment that works. Several therapeutic communities

(TCs) have been established in State and Federal prisons (Tims 1981), but

unfortunately, there has been almost no outcome research conducted. This

chapter summarizes a large-scale evaluation of the Stay’n Out TC, which has

operated programs for male and female inmates in the New York State

correctional system for more than 12 years.

There is an obvious need for effective, prison-based drug treatment programs,

particularly given the high incidence of severe drug problems among State

prison inmates (Kalish and Masumura 1983). According to the Bureau of

Justice Survey of 12,000 State prison inmates, more than three-quarters of the

inmates had used illicit drugs; 56 percent reported using drugs within the month

just prior to committing the crime for which they were incarcerated; and 33

percent admitted using drugs at the time of the crime. Comparisons with drug

abuse within the general population show that inmates were twice as likely to

have ever used illicit drugs and three times as likely to have used drugs during

the past month.

One of the most widely accepted types of treatment for substance abusers

has been the TC. Within the community, TCs have been shown to be effective

SOURCE: Adapted from Wexler et al. 1990, copyright 1990, American Association for

Correctional Psychology; reprinted by permission of Sage Publications, Inc

156
with clients who have extensive criminal histories (De Leon et al. 1972, 1979,

1982; Nash 1973; System Sciences, Inc., 1973; Sells et al. 1976; Wilson and

Mandelbrot 1977; Holland 1978; De Leon 1984). The positive results of a

S-year followup evaluation of Phoenix House (De Leon et al. 1979; De Leon

1984) is of special importance because the Stay’n Out correctional TC program

is in part based on the Phoenix House model.

The rationale for the establishment of the Stay’n Out prison TC derived from

outcome research on community-based TCs. An important finding was that

successful outcomes (reduced crime and substance abuse and increased

employment) were related to the time spent in treatment (De Leon et al. 1972,

1979; Simpson 1978, 1980). In fact, residents who were sent to the program

by the courts had a better success rate than volunteers. However, community

TCs produce excessively high dropout rates that limit their effectiveness to

the relatively few clients who remained at least 3 months in the program (De

Leon 1979). One of the justifications for the establishment of the Stay’n Out

program was to test the efficacy of the time-in-program (TIP) variable within an

environment where residents are likely to stay longer than 3 months. It was

expected that inmates would find the program unit, which is isolated from the

general prison population of inmates, considerably more desirable than regular

prison units.

Preliminary research on Stay’n Out has shown that this program was successful

in implementing and maintaining positive TC treatment environments capable

of retaining inmates for optimal treatment durations (9 to 12 months). The

program also facilitated positive personality changes as assessed by standard

psychological measures (Wexler and Chin 1981). A preliminary report on

recidivism data also indicated that the program produced positive outcomes

(Wexler et al. 1985). The major objectives of the study described in this chapter

were to rigorously evaluate the effectiveness of prison-based TC treatment and

assess the TIP hypothesis.

RESEARCH DESIGN

This study employs a quasi-experimental design that compares the Stay'n Out

program with two types of comparison groups: (1) inmates who volunteered for

the TC program but never participated (i.e., the no-treatment control group)

and (2) inmates who participated in other types of prison-based drug abuse

treatment programs (counseling and milieu therapy) located in different prisons.

Evaluation studies of treatment programs are sometimes criticized on the

basis that the effects of the treatment are biased because subjects are selfselected in the experimental group. In this study, it is assumed that the quasiexperimental design controls for self-selection bias because the subjects in

157
the no-treatment control group initially volunteered to join the experimental

treatment group.

The sampling pool for the treatment groups included all clients who had

terminated from the programs from 1977 through 1984, and the no-treatment

group consisted of subjects who were placed on waiting lists to enter the prison

TC. Names of subjects were given to the Division of Parole, and a computer

tape was returned with information on men and women who were under its

jurisdiction. The data set includes three types of variables: (1) background

characteristics of the groups (e.g., demographics, prior criminal records);

(2) several time variables, with TIP being of greatest interest; and (3) outcome

variables (arrests, time until arrest, and parole discharge/revocation). Parole

outcome status was obtained as of February 8, 1985. Arrest data were

obtained for all active and discharged parole clients. Hypotheses relating

each of the parole outcome variables to program treatment and TIP are tested

statistically for the male and female groups separately.

Male Study Groups

Parole outcomes are compared among four groups of males. The TC group is

compared with two other treatment groups (milieu therapy and counseling) and

a no-treatment control group. The following paragraphs describe each of the

treatment modalities and their basic differences. Sample sizes are reported for

each group.

Male TC Treatment (n=435). The Stay’n Out program is a modified classical

hierarchical TC that began in July 1977. Program capacity at the time this

research was conducted was 120 inmates. Residents lived in two housing

units segregated from the rest of the prison population. They had contact with

prisoners in the general population only when off the TC unit (e.g., at the

cafeteria, infirmary, library). The staff primarily comprised ex-addicts with TC

experience who served as role models.

The TC program is highly structured. Clients are responsible for maintaining

the program unit. They are given jobs ranging from menial chores, such as

cleaning the latrine, to enforcing house rules for proper conduct. A major

reward for good conduct is promotion to a higher job level with increasing

responsibilities and status. Misconduct is viewed as an opportunity for a

‘learning experience” to develop-often to learn for the first time-appropriate

ways to relate to others. Group activities include encounters (therapy),

seminars (education), and special groups to deal with various unit management

problems. Individual counseling and referrals to community TCs also are

provided (see Wexler and Williams 1986 for a detailed description of the

program).

158
Male Milieu Treatment (n=573). This program is a non-TC milieu drug

treatment program that was established in November 1978. It had a

capacity of 124 and was located in a separate unit from the general prison

population. The program provided residents with individual, group, and

vocational counseling and referral services.

The main differences between milieu therapy and the TC approach are that in

the milieu modality (1) time is less structured, and activities are less regimented;

(2) jobs and social roles are not hierarchically ordered; (3) good conduct is not

rewarded by giving residents greater responsibilities; and (4) interaction with

community TCs is not as extensive. In milieu therapy, clients are treated by

program staff (professional drug abuse treatment counselors), whereas TC

counselors are typically ex-offenders or ex-addicts who serve as role models.

Furthermore, TC clients tend to play a more active role in their own treatment

and in maintaining order within the program. These differences affect all

aspects of life and treatment in these programs.

Male Counseling Treatment (n=261). The counseling drug treatment

program that was established in April 1980 had a capacity of 50 clients.

The clients received counseling (either individual or group) once a week and

were given referral services at termination. The treatment was short term,

usually not lasting more than a few months.

Male No-Treatment (n=159). This group is composed of inmates who

volunteered for the TC but never entered the program. They were placed on a

waiting list but were not admitted to the program because they did not meet the

time eligibility criterion that inmates can be no more than 12 months nor less

than 7 months away from parole eligibility. This group is used as a control to

test explicitly whether the TC program is better than no treatment (implicitly

holding constant differences in initial motivation to join the program).

Female Study Groups

Parole outcomes are compared among three groups of females, The TC

group is compared with a counseling group and a no-treatment control group

There was no milieu therapy program for the women available for this study.

Female TC Treatment (n=247). The female Stay’n Out program is a modified

classical hierarchical TC that began in January 1978. Its operation and the

therapeutic process is highly similar to the male TC described above. Program

capacity at the time of this research was 32 inmates in a segregated housing

unit.

159
Female Counseling Treatment (n=113). A drug counseling program was

established in April 1980 for 50 females. It ceased operating in November

1982. The program provided individual or group counseling once a week on

a short-term basis.

Female No-Treatment (n=38). This group is composed of inmates who

volunteered for the female TC program but never entered the program

because they changed their minds before admission. (There was no time

eligibility criteria for the female TC program.) This group is used as a control

to test explicitly whether the TC program is better for females than no treatment

(controlling for initial motivation).

BACKGROUND CHARACTERISTICS

This section describes the background characteristics of the comparison

samples. Table 1 shows the sample sizes and selected background information

for each group. The ages of all groups were quite similar, with the average for

most of the programs being roughly 29 to 30 years of age. The milieu therapy

program had a slightly higher (statistically significant) mean age of 31.3.

Race was also generally similar for most groups (about 50 percent black, 25

percent white, 25 percent Hispanic) with the exception of the female notreatment group, which had a significantly larger proportion of black inmates.

Among the males, approximately two-fifths of the inmates had received no

more than an eighth-grade education. The female counseling and female notreatment groups were somewhat more educated. More than 90 percent had

more than an eighth-grade education. This was significantly greater than the

female TC group, in which less than 80 percent of the sample went beyond the

eighth grade. Marital status for the groups was similar. For the most part, the

majority of the subjects were single, divorced, or separated. Although the male

counseling group had more married men, overall, there were no statistically

significant differences among the groups.

Composite scores for the severity of prior criminal history and the current

offense (for which the inmate was incarcerated) were obtained from parole

records. The crime history score is a weighted average of prior arrests, jail

and prison terms, felony convictions, probation sentences, and parole

revocations. Scores between 0 and 1 are considered less serious, scores

between 2 and 5 are moderately serious, and scores between 6 and 11 are

very serious. The offense score is a sum of the felony class, if weapons were

involved, and if there was forcible contact in the current offense.

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TABLE 1. Background information

Comparison

Groups

Male Groups

TC treatment

Milieu therapy

Counseling

No treatment

Statisticd

Probability

Female Groups

TC treatment

Counseling

No treatment

Statisticd

Probability

Comparison

Groups

Male Groups

TC treatment

Milieu therapy

Counseling

No treatment

Statisticd

Probability

Female Groups

TC treatment

Counseling

No treatment

Statisticd

Probability

N

a

435

576

261

159

247

113

38

Single

39.5

39.1

31.5

41.2

33.0

34.6

38.9

Race Education

Ageb Black White Hispanic <=8 >=9

29.8 52.2 21 .0 26.8 20.3 79.7

31.3c52.4 24.2 23.5 21.9 78.1

29.6 51.6 22.5 26.0 20.7 79.3

28.9 49.7 23.9 26.4 22.9 77.1

F=7.63 Chi-square=2.61 Chi-square-0.62

<.001 NS NS

30.1 53.4 17.4 29.1 21.2 78.8

29.6 53.1 27.4 19.5 9.0 91.0

28.8 78.9 7.9 13.3 92.1

F=0.72 Chi-square=16.16 Chi-square=10.19

NS <.005 <.10

Marital Statuse Crime Scores

Div/Sep Married History Offense

16.3 44.2 2.47 4.06

13.6 47.4 3.43f4.26

11.2 57.3 2.75 4.31

14.7 44.1 2.94 4.08

Chi-square=2.61 F=10.15 F=1.52

NS <.001 NS

20.0 47.0 1.42 4.2

25.0 40.0 1.72 4.0

Chi-square=1.12 F=1.54 F=0.88

NS NS NS

aN represents the total sample size for each of the study groups. Sample size may

vary for individual variables.

bAge was calculated at the time subjects were released from prison.

cMilieu males are significantly older than males in each of the other groups.

dComparisons of pairs of group means were done using the Student-Newman-Keuls

range test (p=.05).

eMarital status excludes approximately 800 cases.

fMale milieu group has a higher criminal history score than all the other male

groups.

KEY: NS=not significant

161
As one can see from table 1, the male groups generally showed higher crime

history scores than the female groups. The average male scores were in the

moderately serious range. Statistical analysis revealed that the male milieu

treatment group score was significantly higher. The female groups had scores

that were in the less serious range, and there were no significant differences

among the groups. The offense scores were similar for all male and female

groups, with no significant differences.

There are several important time variables in this research. Of primary concern

is the effect of the TIP on outcome. Table 2 shows the background time

variables for all the male and female groups. The variables include months in

program, months in prison (current sentence), months in prison postprogram

(i.e., the time between program termination and release from prison), and

months on parole supervision (i.e., time from prison release to expiration of

parole). To the extent that there are statistically significant differences in these

variables between the groups, variations in time could confound the relationship

between program treatment and outcome.

The average TIP ranged from 5 to 8 months across the program groups.

Among males, the TC and milieu treatment clients’ average TIP was

significantly greater than for the counseling treatment group. TIP for the male

milieu treatment clients was also significantly greater than TIP for the male TC

residents (7.2 months). Among the female program groups, the female TC

clients had significantly more TIP than the female counseling treatment clients.

Total time in prison for the current sentence was generally longer for males than

females. The male groups’ average time in prison varied between 31 and 38

months. The male milieu treatment group’s average prison time was

significantly greater than the other male groups, The female groups ranged

from 19 to 32 months in prison, with the female counseling group spending

significantly more time in prison than the TC group and the no-treatment group.

Some of the treatment residents returned to the general prison population after

they terminated from the program. The time clients spend in prison after

treatment may affect parole outcomes if the TC treatment effect is undermined

while they are under more punitive prison conditions. The average time in

prison after program termination was approximately 6 months for most of the

male and female program groups. Among the male groups, the TC clients

spent significantly more time in the prison after release from the program than

the counseling program clients did. The differences between the female

treatment groups were not significant.

162
TABLE 2. Time variables (mean number of months)

Prison

Comparison Groups In Program In Prison Postprogram

Male Groups

TC treatment 7.2a

30.5 6.8d

Milieu treatment 8.2b

37.8c

5.9

Counseling treatment 5.3 31.5 4.8

No treatment NA 34.5 NA

F statistic 21.6 10.6 5.0

Significance <.001 <.001 <.01

On Parole

Supervision

34.7

40.6e

41.3

41.2

3.2

<.05

Female Groups

TC treatment 6.5 24.0 6.5

Counseling treatment 5.3 31.7f

6.2

No treatment NA 19.1 NA

F statistic 4.8 11.3 0.2

Significance <.05 <.001

33.4

34.5

30.5

0.2

a

TC group had significantly more TIP than counseling group.

bMilieu group had significantly more TIP than counseling or TC group

cMilieu group spent significantly more time in prison than counseling or TC group.

d

TC group spent significantly more months in prison after treatment than the

counseling group.

eMilieu group had significantly more months on parole supervision than TC group.

f

Female counseling group spent significantly more months in prison than female

TC groups and no-treatment female group.

KEY: NA=not applicable

Months on parole supervision is a measure of “time at risk”; it is the observation

period in which outcomes were recorded. The male groups generally had

longer durations on parole supervision than the female groups. Table 2 shows

that the male groups ranged between 35 and 41 months on parole supervision.

The male milieu treatment group had a significantly longer duration of parole

supervision than the TC treatment group. Months on parole supervision for

the female groups ranged between 30 and 35 months, with no significant

differences between the groups,

PAROLE OUTCOME FINDINGS

The effects of the TC treatment and other treatment modalities on three parole

outcome variables were analyzed: (1) the percent of the group arrested, (2) the

mean time until first arrest (for those arrested in each group), and (3) the

percent of the group positively discharged from parole. The percent arrested

163
is the proportion of the group that was arrested at least once while on parole.

The time until arrest is calculated as the number of months between the time

offenders are released from prison and the time they are arrested for the first

time. This variable is used to measure how effective the programs are at

delaying criminality among offenders who recidivate. Positive parole discharge

is the completion of parole without rule violations, arrests, or revocation. This

variable measures the long-term effects of treatment because the average time

on parole supervision (i.e., “time at risk”) was 3 years.

The evaluation of parole outcomes consists of three analyses. First, differences

between the treatment and no-treatment groups are compared with respect

to the three parole outcome measures. This analysis does not control for

differences in time in treatment or other background variables. The second

analysis assesses the effects of different lengths of time in the TC on the three

outcome variables. Finally, a multivariate analysis of the effect of time in TC

treatment on time until arrest, controlling for background variables and “time at

risk,” is reported.

Comparisons of Overall Treatment Effects

This section presents findings of tests of the hypothesis that treatment in the

TC is more effective than other prison treatment modalities and no treatment.

The analyses relating the study groups to each of the parole outcomes are

discussed by first describing the overall differences between the groups and

then statistically comparing the effects of the groups on each of the dependent

variables.

Overall Differences. Table 3 shows the three parole outcomes for each of

the comparison groups. The pattern of arrests for the males is as hypothesized,

namely, the percent arrested is lowest for the TC (26.9 percent) and increases

as the intensity of treatment decreases (to a high of 40.9 percent for the notreatment group). The time-until-arrest variable ranges from a mean of 11.4

months for the male milieu group to 15 months for the no-treatment group.

Approximately 60 percent of the TC group received positive parole discharges,

but this rate was not significantly different from the rates for the other male

groups.

Overall, there were no significant differences among the female groups. Table

3 shows that the female TC group had the lowest percent arrested (17.8

percent) and the highest percent positively discharged from parole (77.2

percent), and the group differences approached significance (p<.10). Although

the mean time until arrest for the no-treatment group (8.6 months) was several

months less than for the TC group (12.4 months) and the counseling group

(14.6), these differences were not statistically significant.

164
TABLE 3. Parole outcomes

Positive

Parole Dischargeb

Comparison

Groups

Male Groups

TC treatment

Milieu

Counseling

No treatment

Statistic

Significance

Arrested

N Percent

117 26.9

198 34.6

104 39.8

65 40.9

Chi-square=17.2

p<.001

Mean Months

Until Arresta N Percent

13.1 157 58.1

11.4 164 52.6

12.0 69 52.7

15.0 66 60.6

F=2.32 F=3.40

p=.07 NS

12.4

14.6

8.6

F=1.03

NS

Female Groups

TC treatment 44 17.8 98 77.2

Counseling 33 29.2 58 68.2

No treatment 9 23.7 9 52.9

Statistic Chi-square=5.37 Chi-square=5.35

Significance p=.07 p=.07

aRepresents time until arrested for prisoners who were arrested after their release

from prison

b

For parole discharge data, 401 cases are missing for males, and 169 cases are

missing for females because these subjects had not been discharged by the time

the data set was prepared for analysis.

KEY: NS=not significant

Percent Arrested. Table 4 shows the results of statistical tests comparing the

percent arrested (and the percent positively discharged from parole) between

the TC and other groups. Among the male study groups, the TC was

substantially more effective in reducing the percent arrested than the

comparison treatment groups and the no-treatment group.

The female TC was also significantly more effective in reducing the percent

arrested in comparison with the counseling group (p<.05). However, there was

no statistical difference between the percent arrested in the female TC group

(17.8 percent) and the no-treatment group (23.7 percent, table 3). The small

sample size for the no-treatment group (n=38) may have attenuated the chisquare statistic even though the direction of the relationship is as hypothesized.

Percent Positively Discharged From Parole. The percent positively

discharged for the male TC was somewhat higher than for the alternative

165
TABLE 4. Paired comparisons of parole outcomes

Comparison

Groups

Arrested Positive Parole Discharge

N Percent Chi-square N

Male Groups

TC group

Milieu

117 26.9 157

198 34.5 6.71* 164

TC group 117 26.9 157

Counseling 104 39.8 12.6** 69

TC group

All comparison

groupsa

117 26.9 157

367 37.0 13.7** 229

Female Groups

TC group

Counseling

44

33

17.8

29.2 6.0"'

98

58

TC group

All comparison

groupsb

44 17.8 98

42 27.8 5.4"' 67

a

lncludes milieu, counseling, and no treatment

b

lncludes counseling and no treatment

*p<.01

**p<.001

***p<.05

Percent Chi-square

58.1

52.6

58.1

52.7

58.1

54.2

1.82

1.08

1.16

77.2

68.2

77.2

65.7

2.1

3.7

treatments. Although the male no-treatment group had the highest percent

positively discharged, it was not statistically significant compared with the TC

group.

The data in table 4 show that the percent positively discharged from parole

among the female groups was in the direction hypothesized; that is, the TC

program had the highest percent (77.2 percent), followed by the counseling

group (68.2 percent), and then the no-treatment group (52.9 percent, table 3).

Although the female TC group had a significantly higher percent positively

discharged from parole than the no-treatment group (p<.05), the difference

between the TC and the counseling group was not statistically significant.

Time Until Arrest. Time until arrest is used as an indicator of the extent

to which treatment delays criminal behavior. The relationship between the

166
study groups and time until arrest, as reported in table 3, does not support the

hypothesis that TC treatment delays arrest while on parole. Among the male

groups, there is a tendency for the TC treatment to delay arrest more than the

other treatment modalities but not more than the no-treatment group. No such

tendency was found for the female group. The failure to find a relationship

between the study groups and time until arrest may be attributed to the fact

that the parolees who were arrested represent a biased sample; that is, they

have failed.

Time-in-Program Effects

Program participants were divided into five subgroups according to the

amount of time they were in treatment (less than 3 months, 3 to 5.9 months,

6 to 8.9 months, 9 to 11.9 months, and more than 12 months). Extensive

analyses were done of the TIP effects on percent arrested, time until arrest,

and percent positively discharged from parole. The interested reader may

obtain all statistical tables and figures by contacting the senior author. For

the purposes of description and sake of parsimony the significant effects are

outlined, and a few sample figures are provided that graphically depict the

consistent TIP effect.

The general data pattern was that, as time in the Stay’n Out program

increased to as much as a year, positive parole outcomes increased,

followed by less positive outcomes for those who stayed longer than a

year. The basic quadratic pattern that was demonstrated for by males

is shown in figure 1.

Time Until Arrest. Figure 1 graphically shows the effect of TIP on time until

arrest for each of the male treatment groups. There appears to be a trend for

the TC group with the average time until arrest increasing as the time in the

program increases. The mean for clients in the program less than 3 months

was approximately 9 months; for clients in the program between 9 and 11.9

months, the average time until arrest increased to a peak of 18 months; and for

the clients in the program more than 12 months, time until arrest decreased to

an average of 14 months. The downward trend in time until arrest after 12

months suggests that for the TC male group there is a quadratic relationship

between TIP and time until arrest. That is, as TIP increases, time until arrest

rises and then falls.

Regression analyses relating time until arrest to the quadratic form of TIP were

conducted for the male TC group. The quadratic term for TIP, which reflects the

9- to 11.9-month peak in time until arrest, provides a significant contribution to

time until arrest (R2&058, p=.031). The relationship between TIP and time until

arrest was less defined for the females.

167
FIGURE 1. Time until arrest and positive parole discharge by program by

time in treatment: Males

168
Percent Positively Discharged From Parole. Analyses of TIP effects on the

percent positively discharged from parole revealed impressive findings. The

pattern of results resembles the time until arrest data reported above. There

appears to be a strong positive relationship between months in program and the

percent positively discharged from parole for the male TC group in treatment for

up to 12 months. The percent of male TC positive parole discharges increased

from 49 percent for the less-than-3-month group to a peak of 77 percent for the

9- to 11.9-month group and then decreased to 57 percent for the more-than-12-

month group. The relationship between the percent positively discharged from

parole and TIP fluctuates for the other treatment groups.

The female data resemble the male results. Female TIP data show an increase

in positive parole outcomes from 79 percent for less than 3 months and to a

peak of 92 percent for 9 to 11.9 months. This is followed by a decrease to 77

percent for the clients who remained in the program more than 12 months.

Multivariate Analysis

Multivariate (logistic regression) analyses were conducted to statistically

evaluate the TIP results and assess whether the basic TIP findings were

independent of or related to other factors (such as age or criminal history).

The dependent variable in the multivariate analysis was time until arrest for

TC males after they had been released from prison. (Female clients were

excluded because the number of cases was not adequate for statistical

analysis.) Multivariate analyses of the percent arrested and the percent

positively discharged from parole were conducted; however, the findings are

not reported here because tests of the model (relating these outcomes to TIP

and client background characteristics) did not prove statistically significant.

Two sets of independent variables were entered in a stepwise multiple

regression analysis of time until arrest for TC males. Background factors

included age, total criminal history score, and the length of time in prison

after treatment. These variables were included in the model because

differences in their means were statistically significant. The second set of

variables measured time in TC treatment. Because time until arrest appears

to increase for those who were in the TC for as much as 1 year and then

declines for those who stayed in the program for more than 12 months, the

TC TIP variable was entered in its quadratic form (i.e., both as linear and

squared functions).

Table 5 shows the results of the multiple regression analyses. Age and

criminal history scores are significantly related to time until arrest. The

169
negative association between time until arrest and prior record may result

because more serious offenders are arrested sooner than others. The

positive relationship between time until arrest and age indicates that older

offenders who are arrested take slightly longer to recidivate.

TABLE 5. Time until arrest (multiple regression analysis)

Variable Statistic

Age

Duration of parole supervision

Criminal history score

Postprogram prison time

TC treatment

Milieu therapy treatment

Counseling treatment

Time in TC

Time in milieu

Time in counseling

Time in TC, squared

Constant

Multiple R

R square

Adjusted R square

Standard error

F

.434

.188

.166

9.390

8.600*

*p<.01

*p<.05

B Coefficient

.483

.078

-.618

-.164

-5.983

-3.285

-3.194

.859

-.151

-.128

-.033

-1.295

Beta F

.323 41.354*

.220 22.832*

-.162 9.994*

-.128 7.262*

-.268 6.814*

-.1.57 3.303

-.120 2.278

.383 5.344**

-.085 1.798

-.036 .321

-.279 4.878**

The most important findings are that the TIP variable for TCs is significant

and positively related to time until arrest, as hypothesized, and that TIP

squared is negatively related to time until arrest. That is, the time until arrest

is greater for residents who complete the program in less than 12 months than

for those who are released after 12 months. The regression analysis shows

that when potentially confounding variables associated with time until arrest

are controlled for, the basic results in the univariate analysis are supported.

Although the explanatory power of the equation is moderate (R2=.21), the

hypothesis that increases in TIP (up to 12 months) would increase time until

arrest is supported.

170
Analyses of reincarceration data for the same groups (up to 9 years after

release) provided results that were highly similar to the parole outcome data.

A detailed analysis of the reincarceration findings is included in a National

Institute on Drug Abuse (NIDA) report (Wexler et al. 1988a).

DISCUSSION

This is the first large-scale, long-term study that provides convincing evidence

that prison-based TC treatment can produce significant reductions in recidivism

rates. The three propositions examined received empirical support: (1) Stay’n

Out was effective in reducing recidivism rates (that is, treatment in Stay’n Out

is more effective than no treatment in prison); (2) the TC approach was more

effective than other prison treatment modalities (e.g., milieu therapy,

counseling) in reducing recidivism; and (3) the longer that Stay’n Out clients

remained in the prison TC program, the more successful they were after

release.

The major findings are that the TC was effective in reducing recidivism, and

this positive effect increased as TIP increased, but it tapered off after 12

months. These findings suggest a dosage model where greater exposure

to treatment produces a positive effect up to the point of satiation. Positive

completion of parole, no arrest, and time until arrest increased with time spent

in Stay’n Out but not in the other treatment modalities. These decreases in

recidivism after treatment in Stay’n Out are consistent with earlier studies of the

program that showed reductions in parole revocations (Wexler and Chin 1981;

Wexler et al. 1985). The TIP findings replicate and support similar findings in

outcome studies of community-based TCs (De Leon et al. 1979; Simpson

1980).

Perhaps the most provocative finding was the unexpected decline in positive

outcomes for the more-than-12-month TC clients, Discussions with program

staff provided a potential explanation for the unexpected TIP result. Stay’n Out

is based on the classic hierarchical TC model (e.g., Phoenix House), which

engages clients in a highly structured treatment environment that emphasizes

personal development, internalization of prosocial values, and a strong sense

of responsibility. Upon admission, clients are given low-level jobs and are

granted little status. During the early phases of treatment they are provided

opportunities to earn higher level positions and increased status through

sincere involvement with the program and hard work. When clients have spent

12 months in community TCs, they usually enter the reentry phase, in which

they go into the community and try out their TC “tools” under the guidance of

program staff.

171
Within prison, however, the New York State Parole Board controls release

into the community. Thus, when some clients who are ready for reentry are

denied parole, they are forced to remain in a situation that is disappointing

and frustrating. After being in the program for 12 months there are no further

status levels in the Stay’n Out program to which they can aspire. Stay’n Out

staff report that if the appropriate time for reentry (after approximately 9 to 12

months) is missed, clients become disillusioned and gradually reduce their

involvement in the TC. The program staff believes that these disillusioned

clients are less likely to benefit from further prison TC treatment and less likely

to enter community treatment programs after release.

The important and clear TIP effect found in this research along with the

9- to 12-month optimal treatment durations is not in agreement with some

other prison rehabilitation studies (Izzo and Ross 1990). However, these

studies did not include substance abusers and used other types of treatment

approaches. The TIP effect is well established in the substance abuse

literature (De Leon et al. 1979, 1982; Simpson 1980).

Reviews of the prison rehabilitation literature (Gendreau and Ross 1979,

1987; Wexler et al. 1988b) have identified several characteristics that

successful treatment programs have in common. They (1) are based on

social learning theory; (2) employ authority structures with clear rules and

sanctions, anticriminal modeling, and reinforcement of prosocial behavior;

(3) train clients in pragmatic personal and social problemsolving; (4) have a

program staff that utilizes community resources; (5) encourage empathic

relationships between staff and clients that are characterized by open

communication and trust; and (6) employ ex-offender and ex-addict

counselors to serve as credible role models of successful rehabilitation.

Stay’n Out provides an example of a successful program that employs

these treatment principles (Wexler and Williams 1986).

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ACKNOWLEDGMENTS

This report was supported by NIDA grant DA-03310-3 to Narcotic and Drug

Research, Inc.

Points of view or opinions in this document do not necessarily represent the

official position of the U.S. Government or Narcotic and Drug Research, Inc.

AUTHORS

Harry K. Wexler, Ph.D.

Senior Principal Investigator

Gregory P. Falkin, Ph.D

Research Scientist

Douglas S. Lipton, Ph.D.

Director of Research

174
Andrew B. Rosenblum, Ph.D.

Research Scientist

Narcotic and Drug Research, Inc

11 Beach Street

New York, NY 10013

175
Obstacles to the Implementation

and Evaluation of Drug Treatment

Programs in Correctional Settings:

Reviewing the Delaware KEY

Experience

James A. Inciardi, Steven S. Martin, Dorothy Lockwood,

Robert M. Hooper, and Bruce M. Wald

INTRODUCTION

Several recurring and linked themes have punctuated the many discussions

and debates associated with Federal policy initiatives in the contemporary “war

on drugs.”

First, there is the intricate relationship between drug use and crime and the

disagreements as to whether drug use should be dealt with as a medical/public

health problem or as a criminal problem (Office of National Drug Control Policy

1989, 1990; Hamowy 1987; Musto 1987; Jonas 1989) Often coupled to these

arguments is the recommendation, albeit from outside the substance abuse

field, that the legalization of drugs is the only logical and pragmatic solution to

the violence and other problems associated with a criminalized drug market

(Nadelmann 1988; Trebach 1989).

Second, among many of those who are generally supportive of the war on

drugs, there is the opinion that far too much emphasis has been placed on the

Federal supply-reduction enterprise (enforcement and interdiction), to the

overwhelming neglect of the more important demand-reduction initiatives

(Inciardi 1986; lnciardi and McBride 1989; Clayton 1989; Senate Judiciary

Committee and the International Narcotics Control Caucus 1990).

Third, and perhaps most germane, are the data supportive of compulsory and

coerced treatment for drug offenders (Leukefeld and Tims 1988; Hubbard et al.

1989; De Leon 1988; Platt et al. 1988). Evaluation studies have demonstrated

176
that the key variable most related to success in treatment is length of stay and

that offenders who are coerced into treatment tend to remain longer than those

who voluntarily commit to treatment.

As an outgrowth of these debated themes, there has been the rediscovery

that “treatment works.” This, combined with the dramatic growth in prison

populations during the 1980s (in great part a direct result of the war on drugs),

has resulted in widespread interest in drug abuse treatment not only as an

alternative to incarceration but also as an adjunct to incarceration. Delaware’s

KEY therapeutic community (TC) is a direct outgrowth of this renewed interest

in rehabilitation within a correctional setting.

PROJECT REFORM

In 1986, encouraged by the growing body of evidence of (1) the relationship

between drug use and crime, (2) the value of treatment in reducing the

criminality of drug-dependent persons, and (3) the overall pressures on

correctional systems brought about by demands for more prison sentences

and longer prison sentences for drug offenders, Federal legislators

appropriated the first of several special funding packages for demand

reduction. More specifically, when the Anti-Drug Abuse Act of 1986 allocated

funds for drug enforcement, prevention, education, and treatment, the Bureau

of Justice Assistance (BJA) was designated as the lead agency for sponsoring

correctional treatment initiatives. The key BJA effort in this regard was the

Comprehensive State Department of Corrections Treatment for Drug Abuse

program. The program was designated “Project Reform” by Narcotic and

Drug Research, Inc. (NDRI), which was selected by BJA as national coordinator

for the undertaking. The initial States to participate in the BJA/NDRI venture

included Delaware, Alabama, Connecticut, New York, Florida, and New Mexico.

The TC emerged as the primary drug abuse treatment approach by Project

Reform for several reasons. First, there is considerable evidence that

programs based on social learning theory may be the most effective with

drug-involved offenders whose drug-dependent lifestyles evolved over long

periods (Wexler et al. 1985; Wexler and Williams 1986; De Leon and

Ziegenfuss 1986). Second, and perhaps most important, there are many

phenomena in the prison environment that make rehabilitation difficult. Not

surprisingly, drugs seem to be readily available in most prisons. In addition,

there is the violence associated with inmate gangs, often formed along racial

lines for the purposes of establishing and maintaining “turf” and unofficial

control over certain sectors of the prison for distributing contraband and

providing “protection” for other inmates. Finally, there is the prison subculture—

that system of values and norms that, among other things, holds that “people

177
in treatment are faggots,” as one Delaware inmate put it in 1988. Such an

attitude makes providing treatment within the larger inmate population difficult.

By contrast, the TC is a total treatment environment isolated from the rest of

the prison population-separated from the drugs, the violence, and the norms

and values that militate against treatment and behavioral change. The primary

clinical staff members of the TC are typically “recovering addicts,” that is,

former substance abusers who also were rehabilitated in TCs. The treatment

perspective is that drug abuse is a disorder of the whole person, that the

problem is the person and not the drug, and that addiction is a symptom and

not the essence of the disorder. In the TC view of recovery, the primary goal

is to change the negative patterns of behavior, thinking, and feeling that

predispose one to use drugs. As such, the overall goal is a responsible, drugfree lifestyle.

THE KEY

By the middle of 1988 Project Reform had sponsored the establishment of

TCs in correctional institutions in several jurisdictions. Delaware’s program,

named the “KEY” by its founders, includes many of the traditional aspects

of TCs—a hierarchical structure, the morning meeting, seminars, individual

counseling, encounter groups, and resident job functions. In addition, the

treatment approach includes weekly Alcoholics Anonymous (AA) and

Narcotics Anonymous (NA) meetings, branch groups, transactional analysis,

and psychodrama. The AA and NA meetings follow the standard 12-step

approach and are facilitated by AA/NA chapters from outside the prison.

The branch group is a specialized dynamic in which 10 or more residents

meet regularly to share thoughts, feelings, and attitudes. Rather than serving

as a confrontational group, its purposes are the sharing of innermost feelings

and forming bonds of trust and group cohesion. Transactional analysis

involves the appraisal of the roles one plays in his or her interactions with

others. Psychodrama entails the reliving and exploration of unresolved

personal conflicts and bringing them to closure through group facilitation.

The KEY began operations on July 21, 1988, and its experiences represent a

case study in the difficulties of implementing a TC in a correctional system, in

general, and in a somewhat troubled correctional system, in particular. These

difficulties included issues related to initial budget planning, facility location, staff

recruitment, client selection, treatment staff/correction staff interaction, program

autonomy, aftercare, and evaluation.

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IMPLEMENTATION ISSUES

Initial Budget Planning

Although part of the Project Reform effort included technical assistance from

NDRI and several research and clinical consultants, the initial planning

undertaken prior to the BJA award was done without the benefit of expertise

in either drug treatment facility design or TC operations. The result was

an implementation budget that did not include funds for a number of items

necessary for drug treatment programing, in general, and TC treatment, in

particular. This lack of funds extended to program materials, videotaping,

books and other educational elements, printing and copying, and resource

for educational and vocational programs as well as for public relations and

special event activities. Although some of these deficits were overcome

through special arrangements with NDRI, the Delaware Department of

Correction, and a few private contributors, the KEY operated in an atmosphere

of scarce resources during much of its first year.

Choosing the Facility

Not all correctional facilities are appropriate for TC programing. This fact

became painfully apparent during the planning phase of the Delaware effort.

The State’s largest institution, the Delaware Correctional Center (DCC), was the

initial choice for the new TC. It appeared to be a logical choice: DCC houses

the overwhelming majority of Delaware’s felony inmates; the business offices of

the Department of Correction are located nearby; and the facility had a vacant

building that could be transformed into a somewhat isolated drug treatment

program.

When a clinical director and the technical assistance staff were finally retained,

it was quickly determined that DCC was unworkable as a program site. The

issue was a two-pronged problem of security. DCC is an expansive minimum/

medium-security facility with numerous buildings, cell blocks, dormitories, and

open spaces. It is characterized by the considerable and relatively unimpeded

movement of inmates from one place to another. This freedom of mobility

combined with the size of the compound serve to facilitate the use and

trafficking of any variety of illegal drugs.

Moreover, the buildings designated as potential sites for the TC were suitable

for sleeping and individual counseling activities but for little else. Group activity

space was lacking, and program clients would have been required to mix with

the general prison population three times a day for meals and for recreation—

an unwholesome and unworkable situation for effective TC programing. More

179
appropriate quarters eventually were found at the Multi-Purpose Criminal

Justice Facility, known locally as Gander Hill Prison, in Wilmington, DE. The

move to a new location, combined with already crowded conditions at Gander

Hill, resulted in a further delay in startup and slow initial growth.

The limited options of facility space and this final decision to place the program

at Gander Hill affected the composition of the program. The original intent was

to develop a co-ed TC. Due to the strict separation of men and women by the

Delaware Department of Correction and the unwillingness to alter this practice,

women were excluded from this project. To date, women still are excluded.

Staff Recruitment

The staff recruitment problems that occurred in the Delaware experience

also can have a direct impact on the efficient implementation of a TC in a

correctional setting.

First, in these days of renewed and rapid program expansion, there is a general

lack of experienced drug abuse counseling personnel and an acute lack of

experienced TC staff, especially at the leadership levels. In the absence of any

TCs in the State of Delaware from which to draw, Project Reform had to recruit

a program director from Florida and its initial counseling staff from western

Pennsylvania. The associated recruitment, transportation, and moving costs

represented additional and unanticipated budget items that had to be absorbed.

Second, there is the matter of the “professional model” of staffing vs. the

“recovering addict model.” This is sometimes called “the democratic TC vs.

the programmatic TC issue” (Glaser 1981). On a philosophic level, both

seek to foster a family identity but with marked differences. One researcher

has described it as similar to comparing the Society of Friends with the

Church of Rome (Jones 1986). It is true that the programmatic approach—

characterized by intensity, a militaristic orientation, a hierarchical social

organization, and a recovering addict staff-is more appropriate, because

of both the setting (prison) and the problem (drug addiction) for inmates.

The recovering addict model also puts virtually all power and authority in

the hands of the leader, who authorizes use of coercive methods, within

limits, to achieve the desired behavioral changes in clients.

It is in drawing a fine line between a necessarily authoritarian structure in

effecting behavior modification while avoiding a totalitarian society that

programs such as the KEY may be most challenged. The role of the director

takes on great importance. The KEY’s director achieved the necessary

authority without abusing power.

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Resides philosophy and leadership style, the professional and recovering

addict models differ, as their names indicate, in the nature of their staffing.

The professional model espouses the use of only professional staff having

formal education, training, and experience in one of the behavioral sciences,

social work, or counseling. The recovering addict model advocates the use

of ex-addicts/ex-offenders in key leadership and clinical positions. It would

appear that in a corrections-based TC, the most appropriate course would be

a combination model. Recovering addicts are necessary for the positive role

models they represent to prison inmates and because of their firsthand

experience with the types of “con” games and other manipulations in which

drug abuse clients engage. Professionally trained staff members are necessary

for their clinical skills and the degree of therapeutic detachment that is often

necessary in emotionally explosive settings. Lack of a professionally trained

staff also may impede the acceptance of the TC approach by other drug

treatment programs that may rely solely on professional staff and have not

accepted the role of ex-addicts in the treatment process.

Delaware’s KEY program is primarily a recovering addict model, with some

oversight and input from a professional psychologist. Although such partial

oversight serves to contain costs, it reduces the control by professionals over

all day-to-day activities.

Third, whereas it would be difficult to develop and operate a prison/jail-based

TC without recovering addicts, many State departments of correction have

regulations that prohibit the hiring of former felons for work in correctional

facilities. This is the case in Delaware. This problem was circumvented,

however, by directing Project Reform funding not to the Delaware Department

of Correction but to Correctional Medical Systems (CMS), a private for-profit

firm under contract with the State to provide medical services to all Delaware

inmates. As such, counseling staff members at the KEY are actually CMS

employees and are not prevented by their past drug use or criminal record

from working inside the prison walls.

Client Selection

Prior to implementing a prison-based TC, it is crucial that the TC leadership

meet with the prison security, classification, work release, and parole

leadership to discuss and obtain written agreements on client selection and

release eligibility criteria. This necessary groundwork was undertaken and

accomplished only partially by Project Reform, KEY, and CMS staffs. This

lapse in communication led to some negative implications for a few inmateclients and for the KEY program itself.

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The initial criteria for admission to the KEY TC required the inmate to satisfy the

following conditions:

1. Participate on a voluntary basis

2. Be sentenced and not have any open charges

3. Be in the general prison population (as opposed to segregation or isolation)

4. Be eligible for a parole board appearance within 12 to 18 months (and 18 to

24 months from expiration date for those serving mandatory sentences)

5. Have a history of substance abuse or some indication of involvement in the

drug subculture

6. Have no history of aggressive, nonconsensual sexual offenses or arson

charges from the community or within the correctional system

Although these criteria were thought to be stringent enough to satisfy

institutional and parole authorities, such was not the case. A few of the

inmates accepted into the KEY’s initial client cohort, who were parole eligible

in 1989 and 1990, had short-term release dates (i.e., minimum sentence less

good time accumulated) that were beyond the year 2000. The KEY counseling

staff felt that, after spending a year or more in treatment, these clients were

ready to move out of the institution and into work release or parole. However,

the classification boards in the Department of Correction were not convinced.

The results were conflict between the KEY and the classification staff and the

development of a handful of program clients who were stymied and

disillusioned. Since these TC residents were effectively barred from

“graduation” (e.g., movement into work release), some left the KEY on

bad terms, while some remained as senior counselors in the KEY. In doing

so, however, those remaining caused a “dam” at the upper level of the client

hierarchy, negatively affecting the TC model.

Treatment Staff/Correction Staff Interaction

The failure to develop close working relationships with the classification board

in the Delaware correctional system was not the only gap in treatment staff/

correction staff interactions. There was, and continues to be, a drug counseling

program known as Greentree within the Delaware Department of Correction

that had been operating for years in the State’s main facility-DCC. The Project

Reform technical assistance team and the CMS staff hoped that Greentree

would serve as a feeder to the KEY. However, communication failures

182
alienated the Greentree staff. The Greentree counselors had extensive

contacts with the general inmate population. They reported and exaggerated

aspects of the KEY program, resulting in a body of folklore about the KEY that

made client recruitment difficult.

Program Autonomy

In several ways, the KEY has had only minimal control over its own fate.

Part of the problem is grounded in the differing philosophical orientations of

the KEY and the Department of Correction. Whereas KEY staff members have

a clinical view of inmates as subjects for rehabilitation, corrections staff persons

have an essentially cynical view of inmates as subjects for custody and control.

Although there is some understanding and consideration of each other’s

missions, in many ways the two philosophies remain mutually exclusive.

A direct result of these differences can be seen in KEY expansion. It would

appear that, as a consequence of custodial concerns and the crowded

conditions at Gander Hill Prison, program growth tends to be at the whim

of the Department of Correction and the State legislature. Although this is

understandable from political, administrative, and pragmatic points of view, it

tends to be frustrating from a clinical standpoint. Expansion of any program

involves much more than additional beds and housing. Therefore, the clinical

staff should be involved with expansion plans. This has yet to occur in

Delaware.

Aftercare

Certainly, the most problematic aspect of the KEY implementation involves

aftercare. BJA funding included resources for the planning and realization of

the institutional phase of treatment; however, no monies were allocated for a

community-based transitional facility. When the State of Delaware assumed

responsibility for the continued funding of the KEY, again, only the institutional

phase of treatment was supported. The result is the “graduation” of KEY clients

into the Plummer Center, a work release facility in Wilmington, DE. Since the

Plummer Center accepts work releasees from all the State’s institutions, as well

as Delaware-resident releasees from Federal institutions, the uncontrolled

environment can do much to undo progress in the KEY by throwing the

recovering clients abruptly into an environment that is contaminated with the

outside influences of the street-the drugs, the violence, and the attitudes and

values that militate against rehabilitation. As such, appropriate continuity of

care is lacking. Although the KEY recently placed one of its counselors at the

Plummer Center on a 40-hour per week basis, TC treatment does not extend to

the community-based setting, nor is there any systematic program of transition

to the outside.

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EVALUATION ISSUES

Since Project Reform was a “treatment-driven” rather than a “research-driven”

experiment, funds were not allocated for a formal followup evaluation. The plan

was for the technical assistance team to help the participating States develop

research proficiency, so that each State eventually could evaluate their BJAfunded programs. In theory, at least, this was a fine idea; putting it into practice

in Delaware turned out to be another matter entirely.

Nationally, the research capability, expertise, and resources of State

correctional systems exist along a continuum. At one end, there are the

States of Wisconsin, California, New York, and Florida; the Federal system;

and a few other jurisdictions that have a history of funding and conducting

correctional research-all of which are sustained by permanent trained

research staffs and sophisticated data systems. At the other end of the

continuum is the State of Delaware, which currently has no research staff

within the Department of Correction, has never conducted impact or evaluation

research, and has a data system that, literally, no one appears able to access

and use! As such, even current basic demographic characteristics of the

Delaware prison population are unreliable or unobtainable.

Despite all these difficulties and limitations, systematic assessment of the KEY

TC has begun. With support from the National Institute on Drug Abuse (NIDA),

a long-term field followup evaluation has been initiated. In the short term, the

preliminary evaluation efforts suggest that the KEY has a promising future. In

terms of numbers, as of April 30, 1990, a total of 97 clients have entered the

KEY since it opened its doors on July 21, 1988. For its first 12 months, the KEY

was only a 20-bed facility. During August 1989, it expanded to 30 beds; in

February 1990 it expanded to a 70-bed facility. At present, 68 of these beds

are occupied, and the vacancies are only a matter of scheduling transfers to

the program by the Department of Correction. Of the original 20 clients, 12

graduated from the program and moved into work release. Of these, five

have successfully completed work release. The average length of stay in work

release was 120 days, and random urinalysis found all KEY graduates to be

drug free while in work release. Of the graduates who completed work release,

however, one reportedly has returned to drug use.

The current KEY residents differ in several ways from the general inmate

population. This is undoubtedly largely a function of the selection criteria for

admission. KEY residents are more likely to be black, to be older, to have prior

treatment experiences, and to have used multiple drugs in the past. Given the

nature of the TC experience-an extreme method of treatment for those for

whom less intensive procedures have been unsuccessful—only the program’s

184
high percentage of black participants is surprising. in an assessment of the

current KEY program population done in May 1990, 80 percent of the clients

were black, 17 percent white, and 3 percent from other ethnic groups. More

than 70 percent have never been married. They had an average of 13 arrests,

2 drug arrests, almost 5 years previous time served in prison, and 2 previous

attempts at substance abuse treatment before the KEY. Table 1 gives the

percentage breakdowns by first drug abused and the primary and secondary

drug of abuse before incarceration.

TABLE 1. Percent of KEY clients in May 1990 reporting on first drug abused

and on drugs abused in last 3 months before going to prison

Drug Type

First Drug

Abused

Primary Drug

Last 3 Months

Secondary Drug

Last 3 Months

Alcohol

Marijuana

Cocaine

Heroin

Other opiates

Amphetamines

Other drugs

Only one drug

ever abused

36 6

36 6

13 62

11 20

0 6

0 0

4 0

__ __

24

20

20

7

2

6

3

18

Whereas alcohol and marijuana are the most common first drug used, cocaine

predominates as the preincarceration drug of abuse; 82 percent of the KEY

clients say it is their primary or secondary drug of abuse. KEY clients who were

not dealing cocaine at the time of arrest estimated their per day expenditures on

cocaine at more than $200, on average.

There are some interesting differences between the black and the white KEY

clients. Whites have much longer records than blacks; whites average 30

arrests and 12 years in prison, whereas blacks have 10 arrests and less than 4

years in prison, on average. Whites and blacks report similar distributions on

first drug abused in their lives; however, whites report more cocaine, less

heroin, and more alcohol abuse before incarceration than blacks. Whites also

report abusing more different kinds of drugs than blacks. These findings,

coupled with the presence of more blacks in the KEY than would be expected,

may suggest that blacks are treated more harshly than whites for drug offenses

in Delaware.

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In all, these data on KEY clients indicate that the program is being directed at a

group of inmates with serious substance abuse problems who have not been

successful in previous treatment attempts. Efforts in the KEY program at

present are more concentrated on minority offenders, where current national

statistics suggest that treatment is more needed and less available. In the short

term, there is evidence that KEY graduates are resisting a return to drug use.

This does not mean that experience with the KEY has been a success for all

clients. Besides the one relapse case among post-work-release graduates, 22

KEY residents left the program prematurely: 14 were voluntary dismissals (5 of

whom have returned to the KEY), and 8 were terminated by staff decision.

Twelve of the clients who never returned to the KEY were systematically

interviewed in May and June 1990. Their general profile is similar to that of

current KEY clients. In other words, program dropouts do not differ from those

who remain in the KEY by criminal history, drug use, or other demographic

characteristics. Those inmates who did not complete the KEY remained in the

program for 2 or 3 months, on average. However, three of them left the

program after 10 months because the Department would not transfer them to

work release; these clients felt that the KEY had done all it could do for them

while they were still in prison.

All those interviewed made positive remarks about the KEY. The most

satisfaction was expressed about the individual and group counseling sessions,

which they found most helpful with their alcohol, other drug, and emotional

problems. Similarly, positive opinions were reported by the overwhelming

majority of these former clients about the enforcement of program rules and

regulations, the fair and equal treatment of clients, staff/client relationships and

interactions, and staff understanding of client problems.

On the negative side, almost all these former clients complained about the lack

of educational/vocational opportunities offered by the KEY. This situation is the

consequence of the KEY’s segregation from the rest of the prison and the lack

of space and resources to provide these services for KEY residents.

Only three of those interviewed felt they were “picked on” unfairly while at the

KEY. Two left the program because they felt it was too confrontational. The

remaining seven of those interviewed left due to staff-participant conflicts. Most

of these conflicts centered around the authority, power, and lack of professional

training of senior residents and the large amount of discretion allowed by the

director. Interestingly, most of those interviewed recognized that these conflicts

were a result of the Department of Correction barring senior participants from

necessary classification to work release. They felt that if residents moved out of

the KEY program as designed many of these staff problems would be resolved.

186
Overall, both those who left voluntarily and those who were expelled from the

KEY saw the need and positive effects of such treatment and had good things

to say about the program.

RECOMMENDATIONS

In planning for a corrections-based TC, several things are of the utmost

importance:

1.

2.

3.

4.

5.

Since effective drug treatment cannot be accomplished in the presence

of drug use and the other trappings and influences of the prison culture

that militate against rehabilitation, the TC must be fully separated from

the rest of the penitentiary population. This was eventually accomplished

at the KEY. Although the KEY does not have its own kitchen facilities, its

residents nevertheless do not mingle with other inmates at meal time.

All meals are prepared in institutional kitchens and then delivered to the

TC module. Except for serious health problems requiring an infirmary

admission, medical care takes place at the KEY. The only time that

clients mingle with other inmates is in general equivalency diploma

classes.

From the KEY experience, it is evident that a combination of the

professional and recovering addict models would be most successful

for a TC in the prison setting. Integrating professionally trained with

recovering-addict staff into a team effort should enhance both the

external (corrections officials, politicians, and the media) and the internal

(inmates who doubt the credentials of the staff) credibility of the program.

Since the prison-based TC should be a “facility within a facility,” there

should be adequate funding or arrangements for those other activities

related to successful community integration (e.g., educational and

vocational programs/equipment).

Before implementing any prison-based TC program, it is essential that

procedures for accepting clients into treatment, as well as acknowledged

and accepted requirements for client graduation and movement to work

release and/or parole, be agreed on by program staff, corrections officials,

and parole authorities.

New prison-based TCs should start small and add clientele only after the

program is well established. Such delayed expansion allows time for

problems with corrections officials to be resolved on a small scale. The

concept and tactics of a TC are often difficult for traditional corrections

187

318-269 0 - 92 - 7 QL3
officers and counselors to accept. More importantly, it provides for

training of senior residents and potential staff members from within the

early cohort of TC clients. These graduates provide a pool for additional

staff recruitment that can be both cost-effective and program-effective,

6. Since aftercare is an established condition of successful drug abuse

treatment (Brown 1979), the planning for corrections-based drug treatment

must include arrangements for postrelease care, either through purchasing

bed space in an existing community-based TC or through directly funding a

separate TC transitional facility. The selection procedure should include a

mechanism to ensure that clients will “flow” out of the in-prison setting into

an appropriate community-based transitional facility.

7. Finally, given the problems of staff recruitment, it is recommended that

NIDA, the Office for Treatment Improvement, and the BJA support a

mechanism through which people can be recruited into drug counseling

careers. The primary missions of this effort should be the identification,

training, and accrediting of drug treatment clinicians. A secondary mission

should involve working with State departments of correction to bring about

changes in personnel practices that bar recovering addicts from working in

correctional treatment. It would appear that the most logical place to house

these efforts would be the National Association of State Alcohol and Drug

Abuse Directors, the Therapeutic Communities of America, or a similar

organization. A clearinghouse for corrections-based drug treatment

employment opportunities should be established as well, coordinated

perhaps by the American Jail Association, the National Academy of

Corrections, or the American Correctional Association.

NOTES

1. State prison populations grew by more than 10 percent during 1989. By

year’s end, after a decade of rapid growth, State prisons housed a record

644,000 inmates, with Federal prison inmates numbering 56,500 (New York

Times, May 20, 1990, pp. 1, 32).

2. DCC also has a maximum security unit, but this is a small, isolated

compound segregated from the rest of the facility.

3. The rumor that was spread throughout the prison grapevine was that, once

in the KEY, movement to parole or work release was all but impossible. It

also was alleged that violations of the rules of the KEY resulted in shaved

heads and loss of “good time” credits. During 1989, the Greentree program

was restructured, its counseling staff was changed, and the bad feelings

188
4.

5.

eventually disappeared. At about the same time, some of the KEY’s first

residents began their movement into work release. In addition, senior KEY

clients networked the general prison population to dispel the negative

rumors.

The field followup is being conducted as part of NIDA grant DA-06124,

“Assertive Community Treatment for High Risk Drug Abusers.”

The State prison in Patuxent, MD, is a treatment-oriented facility that is selfcontained and includes its own parole board that acts to review cases in

progress and makes parole decisions on inmates who have completed

treatment. The control of release decisions is considered the key to the

dramatically lower recidivism rates from the institution vs. the rest of the

Maryland system.

REFERENCES

Brown, B.S., ed. Addicts and Aftercare: Community Integration of the Former

Drug Abuser. Beverly Hills, CA: Sage, 1979.

Clayton, R.R. Legalization: An idea whose time has not come. Am Behav Sci

32(3):316-332, 1989.

De Leon, G. Legal pressure in therapeutic communities. J Drug Iss 18(4):625-

640, 1988.

De Leon, G., and Ziegenfuss, J.T., eds. Therapeutic Communities for

Addictions: Readings in Theory, Research, and Practice. Springfield, IL:

Charles C Thomas, 1986.

Glaser, F.B. The origins of the drug-free therapeutic community. Br J Addict

76:13-25, 1981.

Hamowy, R., ed. Dealing With Drugs: Consequences of Government Control.

Lexington, MA: Lexington Books, 1987.

Hubbard, R.L.; Marsden, M.E.; Rachel, J.V.; Harwood, H.J.; Cavanaugh, E.R.;

and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill, NC: University of North Carolina Press, 1989.

Inciardi, J.A. The War on Drugs: Heroin, Cocaine, Crime, and Public Policy.

Palo Alto, CA: Mayfield, 1986.

Inciardi, J.A., and McBride, D.C. Legalization: A high-risk alternative in the war

on drugs. Am Behav Sci 32(3):259-289, 1989.

Jonas, S. Is the drug problem soluble? Am Behav Sci 32(3):295-315, 1989.

Jones, M. Democratic therapeutic communities or programmatic therapeutic

communities or both? In: De Leon, G., and Ziegenfuss, J.T., eds.

Therapeutic Communities for Addictions: Readings in Theory, Research,

and Practice. Springfield, IL: Charles C Thomas, 1986. pp. 19-28.

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Leukefeld, C.G., and Tims, F.M. Compulsory Treatment of Drug Abuse:

Research and Clinical Practice. National Institute on Drug Abuse Research

Monograph 86. DHHS Pub. No. (ADM)89-1578. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1988.

Musto, D.M. The American Disease: Origins of Narcotic Control. New York:

Oxford University Press, 1987.

Nadelmann, E.A. The case for legalization. Pub Interest 92:3-31, 1988.

Office of National Drug Control Policy. National Drug Control Strategy. Report

No. S/N 040-000-00542-1. The White House. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., September 1989.

Office of National Drug Control Policy. National Drug Control Strategy. Report

No. S/N 040-000-00543-9. The White House. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., January 1990.

Platt, J.J.; Buhringer, G.; Kaplan, C.D.; Brown, B.B.; and Taube, D.O. The

prospects and limitations of compulsory treatment for drug addiction. J Drug

Iss 18(4):505-525, 1988.

Senate Judiciary Committee and the International Narcotics Control Caucus.

Fighting Drug Abuse: A National Strategy. Washington, DC: Committee on

the Judiciary, U.S. Senate, January 1990.

Trebach, A.S. Tough choices: The practical politics of drug policy reform. Am

Behav Sci 32(3):249-258, 1989.

Wexler, H.K.; Lipton, D.S.; and Foster, K. “Outcome Evaluation of a Prison

Therapeutic Community for Substance Abuse Treatment: Preliminary

Results.” Paper presented at the annual meeting of the American Society of

Criminology, San Diego, CA, November 1985.

Wexler, H.K., and Williams, Ft. The Stay’n Out therapeutic community: Prison

treatment for substance abusers. J Psychoactive Drugs 18(3):221-230,

1986.

AUTHORS

James A. Inciardi, Ph.D.

Director

Steven S. Martin, M.A

Associate Scientist

Dorothy Lockwood, M.A

Associate Scientist

Bruce M. Wald

Treatment Director

190
Center for Drug and Alcohol Studies

Department of Sociology

Division of Criminal Justice

University of Delaware

Newark, DE 19716

Robert M. Hooper, Ph.D.

Vice President

Correctional Medical Systems

42 Read’s Way

New Castle, DE 19720

191
Evaluation of In-Jail Methadone

Maintenance: Preliminary Results

Stephen Magura, Andrew Rosenblum, and Herman Joseph

INTRODUCTION

There are estimated to be 200,000 heroin addicts in New York City, of whom 80

percent are not in any kind of drug abuse treatment (LaPorte 1988). Heroin

addicts are primarily intravenous (IV) drug users, who account for 24 percent of

new adult and adolescent acquired immunodeficiency syndrome (AIDS) cases

in the United States (Centers for Disease Control 1990) and 43 percent of new

cases in New York City (New York City Department of Health 1990). Human

immunodeficiency virus (HIV) antibody seroprevalence among IV drug users in

New York City is between 50 and 60 percent (Lange et al. 1988; Marmor et al.

1987).

There is a strong and well-documented connection between drug use,

especially IV use, and criminal activity (e.g., Johnson et al. 1985). A 1986

national survey of State prison inmates found that 36 percent of all inmates

reported regular past use of major drugs, including heroin, cocaine, and

phencyclidine (PCP) (Innes 1988). Urinalysis surveillance of felony arrestees

has found substantial rates of heroin positives for male arrestees in large cities:

13 percent in Los Angeles, 18 percent in Chicago, 18 percent in San Antonio,

21 percent in San Diego, and 24 percent in New York; rates are somewhat

higher for females (National Institute of Justice 1990). Twenty-eight percent of

a sample of New York State prison admissions from New York City jails from

December 1, 1987, through January 31, 1988, had histories of IV drug use, and

44 percent of these were HIV seropositive in anonymous testing (New York

State Department of Health 1989). In general, national HIV seroprevalence

rates of jail inmates seem to reflect the rates that characterize IV drug users in

the respective communities (Hammett 1989).

Most of the criminally involved addicts in New York City eventually pass through

the city’s central jail facilities on Rikers Island. Since the early 1970s narcotics

addicts have been able to receive methadone detoxification at Rikers, in a

program initiated by Dr. Vincent P. Dole. Out of a total of 80,000 admissions to

192
Rikers in 1986, 16,000 detoxifications of heroin addicts were performed.1

However, once detoxified addicts are released after legal processing or

completing short sentences, they almost invariably return to drugs and crime.

(Almost all heroin addicts at Rikers have had multiple detoxifications.) A

voluntary alternative to rapid detoxification was created at Rikers in March

1987. The Key Extended Entry Program (KEEP) enables addicts charged with

misdemeanors to be maintained on a stable dose of methadone during their

stay at Rikers (averaging 45 days) and to be referred at release to dedicated

slots in participating community methadone programs.

Thirty-five percent of KEEP-eligible heroin addicts admitted to Rikers are

enrolled in a methadone program at the time of their arrest; KEEP enables them

to continue receiving medication while in jail to encourage return to their

community clinic after release. For the 65 percent of addicts who are not in

treatment when arrested, KEEP is intended to be a route into long-term

community drug treatment. The objective is to break the cycle of illicit drug use

and criminal recidivism. KEEP is the only methadone maintenance program in

the United States for incarcerated heroin addicts and only one of three known

locations in the world where methadone is available to prisoners.2 This chapter

reports preliminary results from a process and impact evaluation of KEEP.

KEEP BACKGROUND AND DESCRIPTION

Prison and jail administrators traditionally have not been receptive to providing

methadone maintenance to incarcerated narcotics addicts. The main reasons

appear to be a philosophical opposition to this treatment modality (an opinion

not limited to correctional personnel) and concerns about the feasibility of

providing methadone in a prison or jail setting (e.g., diversion of medication,

violence, security breaches). Nevertheless, a convergence of the following

factors made it possible to establish KEEP in New York City in 1987:

A rapid increase in the New York City jail population, fueled largely by

increased numbers of drug-related arrests, leading to jail overcrowding and

unrest. This situation heightened awareness among city officials that new

measures to treat addicts must be tried, with the goal of reducing recidivism.

The AIDS epidemic, which also created incentives for city officials to reach

out to untreated IV drug users with improved services.

The efficient operation of the ongoing methadone detoxification program at

Rikers.

193
The commitment of key drug abuse treatment administrators at the New

York State Division of Substance Abuse Services (DSAS), who designed

and funded KEEP, and personnel at Montefiore Hospital, who implemented

KEEP.

The willingness of key city correctional administrators to take a risk with a

controversial program.

The establishment of KEEP at Rikers required the cooperation of diverse

agencies to achieve a common goal despite differences in organizational

philosophies and missions. New procedures to accommodate extended

maintenance on methadone had to be created, new personnel hired, and

facilities made available. The New York City Department of Correction had to

modify regulations about managing and housing inmates involved in the

program, construct new medication stations, and provide the necessary

security. Community methadone programs were enlisted and funded to provide

postrelease patient evaluation and continuing treatment. The Chemotherapy

Services Bureau of DSAS developed the basic concepts and coordinated the

implementation of the program. Montefiore Hospital’s Rikers Health Services

division accepted the challenge of operating KEEP in a tense and overcrowded

urban jail complex. KEEP was piloted in the women’s house, where prior

experience with maintaining pregnant women on methadone for 30 or more

days facilitated the transition from methadone detoxification to methadone

maintenance for the eligible population.

To be eligible for KEEP, a new inmate must be diagnosed as a narcotics addict

by a Rikers physician and must be either a pretrial detainee charged with a

misdemeanor or an offender serving a sentence of up to 1 year at Rikers.

These restrictions on legal status are intended to screen out addicts who might

be convicted of a felony and thus might receive a sentence of more than 1 year,

which would be served in State prison where methadone is not available.

KEEP avoids methadone maintenance for inmates who might be transferred to

State prison, which renders about 75 percent of addicts at Rikers ineligible for

KEEP, although most offenders charged with felonies ultimately are not

transferred to prison. In addition, once addicts complete detoxification, they

may not be placed in KEEP, further limiting the eligible population.

About 3,000 male (77 percent) and female (23 percent) addicts annually receive

methadone maintenance at Rikers through KEEP. KEEP is operated in three

separately administered jail facilities at Rikers: The sentenced men’s house,

the pretrial detainee men’s house, and the women’s house, which serves all

women. Women receiving methadone detoxification or maintenance are

housed together, separately from the rest of the population. Male detainees

194
receiving methadone detoxification or maintenance also are housed together.

Sentenced male methadone maintenance patients reside on the general

wards.3

Eligible addicts who accept the offer of KEEP (virtually all do) are maintained on

30 mg per day if they were not on methadone when incarcerated and 40 mg per

day if they were. (These are also the doses at which detoxification begins.)

Inmates remain at Rikers an average of 45 days (ranging from 1 day to 1 year)

until their cases are adjudicated, bail is made, or sentences are served. At

release KEEP patients who were not on methadone at their arrest receive a

referral to a specified community methadone program with a KEEP clinic;

patients are instructed to report within 24 hours. At the time of this study there

were 12 KEEP clinics in New York City. Outpatient KEEP clinics are operated

under Federal regulations as 180-day detoxification programs. During this

period the goal is to stabilize patients, to evaluate their longer term needs, and

to make a decision for continuance in regular methadone maintenance, transfer

to another type of drug abuse treatment, or discharge from treatment.

Experience with KEEP at Rikers has eased the anxieties that corrections

personnel have about providing methadone to prisoners. Diversion of

medication has not been a problem; the few patients who have attempted

“spit-backs” have been detected and dropped from the program. There have

been no conflicts between inmates who have access to methadone and those

who do not. Moreover, the corrections staff perceives that addicts receiving

methadone are less irritable and easier to manage than other inmates. KEEP

now is viewed as an integral part of the administration of the jail and is accepted

by the wardens as an important program for the treatment of heroin addiction

and as an AIDS prevention measure among the jail population.

METHOD

The core of the evaluation study is a longitudinal followup of a cohort of

KEEP participants and controls to examine (1) how well KEEP is being

implemented and (2) outcomes for participants compared with outcomes of

similar nonparticipants. The controls are heroin detoxification patients with

characteristics similar to those of KEEP patients but who could not be enrolled

in KEEP due to lack of slots or certain technical ineligibilities (e.g., completed

detoxification). The study also provides individualized postrelease casework to

a randomly selected sample of KEEP participants intended to address some of

the transition problems that could interfere with their reporting to or remaining

enrolled in a community methadone program. Programmatic and process

information is obtained by site visits to a sample of community KEEP clinics.

Available data on the KEEP population and on the entire city methadone

195
population (for comparative purposes) are being obtained through the

cooperation of Montefiore Hospital and the DSAS.

This chapter presents data on the characteristics of the KEEP population at

Rikers Island and on patients’ postrelease reporting rates to methadone

programs and treatment retention rates. Process information on the multiple

obstacles to retaining this population in treatment also is presented. The 6-

month postrelease interview followup of KEEP participants and controls was

completed after preparation of this chapter.

The study subjects are 225 randomly selected participants admitted to KEEP at

three “houses” (see above) between November 1988 and July 1990 at Rikers

Island, who were not enrolled in methadone treatment at the time of their arrest.

The study focuses on this population because a pilot study indicates that

methadone patients who are arrested and placed in KEEP are very likely to

return to their community methadone program, which the present research

verifies. Study subjects were selected randomly from eligible KEEP admissions

to achieve the targeted sample size.

Baseline research interviews were conducted with subjects at admission.

Informed consent was obtained, and an incentive of $10 was deposited in

subjects’ canteen accounts. Ninety-nine percent of the inmates contacted for

the study agreed to participate. All interview information was confidential; the

independence of the research project from the correctional system and KEEP

methadone program was emphasized.

RESULTS

Table 1 presents the sociodemographic characteristics of the KEEP sample,

which closely parallels the characteristics of the inmate population at Rikers.

There is substantial instability in living arrangements; few were living in what

they described as their own home before incarceration, and two in five men

described themselves as homeless. Weekly income figures for the week before

arrest represent mainly criminal income from property crimes (i.e., burglaries for

men and shoplifting for women).

Table 2 indicates that most of the subjects are daily users of both cocaine and

heroin. lntranasal heroin use is significantly greater for women, and 22 percent

of women (table 3) report using heroin only intranasally and not injecting any

drug; they also may sniff cocaine or use crack, however. Women as a group

also report significantly less frequent drug injection. It is notable that, although

all subjects said they were using heroin and were medically diagnosed as

heroin addicts, about one-third defined their primary drug problem as some form

of cocaine use.

196
TABLE 1. Sociodemographic characteristics of KEEP participants (n=215)

Characteristics

Ethnicity

Hispanic

Black

White

Other

Age (mean)

Marital Status

Married or common law

Separated

Divorced

Widowed

Single (never married)

Last Grade Completed

Grades 3 to 8

Grades 9 to 11

Grade 12

Some college

Associate degree

College graduate

Major Source of Income (Week Before Arrest)

Stolen cash or goods

Sale of drugs

Prostitution

Legitimate job

Spouse or sex partner

Welfare

Other

Living Arrangement Before Jail

Own home

Another’s home

Homeless

Single room occupancy

Other

Income for the Week Before Jail (mean)

197

Men (n=144) Women (n=71)

38%

47%

15%

1%

27%

62%

10%

1%

34% 33%

16%

17%

12%

2%

54%

25%

7%

10%

4%

54%

5%

39%

41%

13%

2%

1%

6%

44%

36%

13%

0%

1%

69% 77%

16% 1 1%

2% 3%

4% 2%

1% 5%

1% 0%

6% 2%

13%

33%

39%

1 0%

4%

16%

56%

8%

11%

8%

$1,244 $1,070
TABLE 2. Frequency of drug use in past 6 months (percent)

Men Women

Less

Than

Type of Use Daily Weekly Weekly Daily Weekly

Inject heroin* 78 5 1 56 6

lntranasal heroin†25 4 9 44 11

lntranasal cocaine 10 5 8 11 8

inject cocaine†50 9 6 32 7

Inject speedball‡63 7 6 55 6

Crack 31 12 12 39 10

Illicit methadone 2 33 29 6 32

Heavy drinking* 17 12 18 3 3

*p<.001

†

p<.01

‡mixture of heroin and cocaine

Less

Than

Weekly

8

7

6

6

1

7

31

13

TABLE 3. Selected drug use-related AIDS risk behaviors in past 6 months

(percent)

Men

Risk Behaviors

Inject (p<.001)

Visit shooting

gallery

Shoot with

used works

Share cookers

Daily Weekly

81 4

24 10

6 10

26 17

Less

Than

Weekly Daily

1 61

11 21

28 2

19 25

Women

Less

Than

Weekly Weekly

6 7

10 12

8 33

10 14

198
Selected drug use-related AIDS risk behaviors are shown in table 3. Women as

a group report significantly less drug injection than men. IV drug users seem to

have grown more wary of injecting with “used works.” Nevertheless, 54 percent

of the injectors (men and women) continue to report some form of needle/works

sharing in the previous 6 months. Among sharers, 53 percent do not clean

needles/works consistently or effectively. Sharing cookers is common, and 53

percent said they did not know that sharing cookers, cotton, and rinse water

could transmit HIV. Shooting gallery visitors (44 percent of the sample) were

more likely to share and reuse equipment and not clean it effectively.

Table 4 indicates that condom use during various sexual activities is infrequent.

Of the 18 percent of men who report engaging in heterosexual anal sex, 88

percent report usually using no protection. Anal sex has been established as a

relatively efficient route of HIV transmission. Incidentally, almost all of these

men classify themselves as heterosexual.

TABLE 4. Selected sexual AIDS risk behaviors in past 6 months (percent)

Risk Behaviors Men

Vaginal Sex 85

No condom use 63

Condom use some of the time 25

Condom use every time 12

Women

69*

65

14

20

Oral Sex

No condom use

Condom use some of the time

Condom use every time

73 39†

91 71

8 7

1 21

Anal Sex

No condom use

Condom use some of the time

Condom use every time

*p<..01

†

p<.001

18 4*

88 67

4 0

8 33

199
Property crimes are by far the most frequent arrest charges for both men and

women, but this may not be representative of all street addicts, since the KEEP

eligibility criteria exclude the more serious or violent felony offenders (unless

their charges are downgraded soon after incarceration). Both men and women

have extensive criminal histories (table 5). About two out of five subjects report

committing a crime to get a place to stay, which is consistent with their reported

housing instability. Some also admit inviting arrest at least once to obtain

methadone at Rikers, although this does not appear to be a pervasive

“problem.”

The types and numbers of self-reported crimes in the 6 months before latest

arrest are shown in table 6. Men report more burglaries, robberies, weapons

possession, and drug-dealing offenses; women report more prostitution.

Prostitution is not a major category, and this is supported by other interview

data indicating that most of these women specialize as shoplifters. Addict

prostitutes seem to be a separate group whose cases are resolved without

detention at Rikers. Note the large number of crimes reported during just 6

months compared with reported lifetime arrests (22 for men, 27 for women); the

difference is astounding. This finding replicates previous research by Ball and

colleagues (1981), Chaiken and Chaiken (1983) and Johnson and colleagues

(1985), which will be confirmed with official arrest records.

TABLE 5. Criminal history (self-report)

Criminal History Men Women

Age first arrested (mean)

Years incarcerated (mean)

Number of times at Rikers (mean)

Lifetime arrests (mean)

Nondrug arrests (mean)

Ever arrested to get

a place to stay

Ever arrested to get

methadone

18 21*

7 5†

9 8

22 27

18 26

19% 21%

8 % 4 %

*p<.001

†

p<.05

200
TABLE 6. Number of crimes committed in past 6 months

Type of Crime Men Women

Drug possession 165 160

Drug dealing 34 21

Auto theft 7 3

Shoplifting 82 101

Robbery 8 0*

Burglary 28 4*

Weapons possession 17 4*

Prostitution 2 10

Forgery 3 4

Total nondrug crimes 161 127†

*p< .05

†

p<.01

Ninety-five percent of addicts who are offered participation in KEEP accept and

remain in the program while at Rikers. Fifty percent of the subjects report a

previous methadone treatment episode, and 93 percent state that they intend to

report to the designated KEEP community methadone program afler release.

However, only 40 percent expect to be in treatment after a year’s time, which

reflects the general view that methadone should only be a bridge for them to a

drug-free lifestyle. Eighty-six percent expect to be abstinent from illicit drugs at

1 year after release.

Most KEEP participants have considerable anxieties about remaining on longterm methadone maintenance. Sixty percent reported that the “worst thing they

had heard about methadone” was that it “eats the bones” (common variant:

“rots the teeth”), and 90 percent believed this to be true. Forty percent stated

that their “greatest fear” about methadone was that it is “hard to kick” (“too

addictive”), and an additional 20 percent mentioned other fears such as

overdosing. Significantly fewer women than men reported “no fears” (23

percent vs. 40 percent, p<.01). This prevailing folklore about methadone

maintenance in the addict subculture has been documented previously by

Goldsmith and colleagues (1984). However, there seems to be no basis in the

medical literature for fears about these specific long-term side effects (Kreek

1983). It has been suggested that these beliefs may derive from addicts’

previous experiences when undergoing rapid methadone detoxification and/or

being maintained on inadequate levels of methadone, both of which may cause

withdrawal symptomatology (Goldsmith et al. 1984).

201
Table 7 shows the percentage of KEEP patients reporting to their designated

community methadone program after release from Rikers, separately for

participants who were and were not in methadone treatment at arrest; the

reporting rate is significantly higher for the former. Whether this indicates a

differential level of motivation for treatment after release for the two groups is

unclear. Returning methadone patients almost always report to their original

community program, whereas new patients were limited to 1 of 12 KEEP clinics

at the time of the study, whose locations, medication hours, services, and

policies were not necessarily as suitable for them. The reporting rate is

significantly higher for men.

A fairly high reporting rate may not be surprising, if only because of these

subjects’ immediate need for an opiate to prevent withdrawal. An addict

released from Rikers, often in the small hours of the morning with no money,

may have difficulty obtaining heroin on short notice. Thus, a better measure of

treatment engagement is the rate of retention in community methadone

maintenance. Table 7 shows fairly high attrition rates for those who were not in

methadone treatment at arrest; 60 and 67 percent of initially reporting men and

women, respectively, on whom at least 5 months of postrelease data are

available, are no longer attending the community program. Attrition rates for

those who were in methadone treatment at arrest are lower, especially during

the first month after release.3

TABLE 7. Reporting and retention rates (percent)

Reported to community

methadone program

In program at 5 months

after release

Attrition rates

1st month

2nd, 3rd month

4th, 5th month

Not in Methadone Treatment

at Arrest

Men Women

57 (62/108) 42 (27/65)†

23 (25/108) 14 (9/65)

29 (18/62) 44 (12/27)

15 (9/62) 19 (5/27)

16 (10/62) 4(1/27)

In Methadone Treatment

at Arrest’

Men Women

83 (82/99) 79(30/38)

47(47/99) 42 (16/38)

12 (10/82) 20 (6/30)

18 (15/82) 17 (5/30)

12 (10/82) 10 (3/30)

*Data based on random samples of 99 men and 38 women whose records were

traced

†

p<.01

202
DISCUSSION

There are many reasons why KEEP participants do not follow through with their

community treatment referrals or do not remain in treatment long after reporting.

Some of these reasons are clearly centered in the addicts themselves (e.g.,

insufficient motivation for treatment or personal disorganization). There are also

various administrative and systems obstacles to enrollment and retention that

affect the viability of a potentially worthwhile treatment innovation.

Although KEEP participants’ intentions to enter community methadone

treatment and expectations of remaining abstinent are high, continuation in

treatment may be compromised by personal beliefs regarding the nature of

addiction and the efficacy of treatment as well as by unrealistic concerns about

the side effects of methadone. Improved education concerning methadone—

benefits, risks, and outcomes-might reduce addicts’ ambivalence, but given

the “bad press” this modality has been receiving generally, the possibility of

creating a major change in attitudes among the addict population is doubtful.

Another serious barrier to engaging these addicts in community treatment is

their level of deprivation. Methadone program administrators have observed

that KEEP patients as a group have more severe personal and social deficits

than other addicts who apply for treatment. At incarceration almost none hold

jobs (or possess usable legitimate job skills), and most are literally “street

addicts,” without stable living quarters or social supports, heavily involved in

property crimes. The women often support paramours through theft and are

expected to return to such activity after their release. Illegal incomes are high,

but virtually all money is used for drugs, so that most of these addicts are

constantly destitute. Certainly, drug abuse treatment can help an addict

achieve stability, but some minimal level of security is required to enable the

person to comply with outpatient drug abuse treatment program requirements.

Again, although drug abuse is instrumental in creating the difficult situations in

which these addicts find themselves, merely enrolling in treatment will not

automatically result in procuring adequate housing, adequate and legal income,

and supportive family and friends. Methadone programs generally have only

limited ability to assist KEEP patients in obtaining the social, vocational,

housing, medical, and individualized supportive counseling services they may

need to break the cycle of addiction and crime.

KEEP’s ability to help these addicts is seriously impaired by cocaine abuse.

Most KEEP participants use cocaine in some form at arrest about as frequently

as they use heroin, and about one-third say that cocaine (including crack) is

their primary drug problem. Thus, methadone can constitute only part of their

treatment solution. Urinalysis used by community programs shows that the

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patients who report after release from Rikers usually also return immediately

to cocaine use. Methadone programs generally have no specialized therapies

for cocaine use (Kolar et al. 1990). Cocaine use tends to decline the longer

addicts remain in methadone treatment (Magura et al. 1991; Hubbard et al.

1989; Chaisson et al. 1989), but KEEP patients drop out early or are

involuntarily discharged for various reasons.

Dedicated (guaranteed) community methadone slots for KEEP participants

released from Rikers are essential, but during most of the study period study

only 12 community programs were funded to participate. Addicts who consider

entering treatment are likely to be “turned off” by programs far from their homes

with limited medication hours. The original concept of KEEP also involved

making a full range of long-term drug treatment modalities available to KEEP

participants at release. Ready availability of drug-free treatment might have

been a more attractive alternative for some participants given the generally

negative attitudes toward methadone displayed by this population. Thus far,

however, funding and space limitations have restricted community KEEP

programs to the methadone modality.

Various administrative, financial, and systems problems have affected the

efficiency and effectiveness of KEEP. Due to limited funding, KEEP staffing

levels at Rikers have been marginal at best. Counselors have been occupied

mainly with recruitment and have had limited time for discharge planning.

Difficult working conditions at Rikers-tense, noisy, overcrowded, inadequate

office space; summer heat; work delays due to security requirements; long

commutes by public transportation-have led to high turnover of KEEP

correctional staff, which is also true for most of the noncorrectional staff. Thus,

the program usually has been understaffed or staffed with new personnel, many

of whom also are persons in recovery for whom the Rikers environment may be

particularly stressful. It has not been possible to work intensively with the large

majority of KEEP participants to motivate them for long-term treatment and to

develop detailed discharge plans. However, there have been individuals for

whom intensive referral efforts have resulted in good outcomes, such as

admission of clients to community residential programs. In general, however,

owing to funding and implementation problems, the potential of KEEP at Rikers

probably has not been fully realized.

Funding uncertainties also have affected the establishment and operation of

the community KEEP programs. At various times certain KEEP clinics have

frozen enrollment, lowered KEEP staffing levels, or limited KEEP clinic hours

because of funding delays or reductions. It is difficult to assess the exact effect

of these problems on patient retention, but some negative effect is plausible.

Unfortunately, these problems have not yet entirely abated. Nevertheless, the

number of community KEEP methadone clinics now has increased to 20.

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Enrolling patients in Medicaid has been a key issue, because community

programs usually need to obtain Medicaid reimbursement for as many patients

as possible. This requires acceptable identification, which most KEEP

participants do not have and often fail to obtain. There are other steps in the

application process that also must be pursued. As one KEEP patient put it, “It’s

easier to cop drugs.” Some community programs have the resources to guide

patients through the application process, but others do not and will discharge

patients if Medicaid is not obtained.

The KEEP staff is aware of this problem and has been attempting to begin

prescreening for Medicaid and public assistance while inmates are still at

Rikers. The discharge of inmates before the process can be completed, and

the lack of staff to pursue the labor-intensive tasks involved have been

hindrances to this effort. The eligibility obtained is temporary, however, and

requires the inmate to follow up with the public welfare agency afler release.

In addition, only inmates who are expected to remain at Rikers at least another

30 days (usually only sentenced inmates) are eligible for this followup (the

process requires about 30 days). This makes at least half the KEEP patients

at Rikers ineligible for this service.

Various other factors also may affect enrollment and retention in the community

programs. First, KEEP participants who report more than 24 hours afler release

from Rikers are technically ineligible for immediate medication; if not medicated,

they usually depart and do not return. However, some clinics try to be flexible

about this requirement. Second, patients often will not obtain the required

physical examination after admission, which has the immediate effect of

precluding an increase in their methadone dose from the 30 mg received at

Rikers (average dosage in city programs is 45 to 50 mg) and the later effect of

administrative discharge. A special problem is that patients at nonhospitalaffiliated programs often must go to an offsite laboratory for blood work, and at

least one program requires patients to pay for this workup. Failure to obtain the

blood work constitutes an incomplete physical exam and can result in

administrative discharge.

Patients attempting to avoid renewed criminality must receive some financial

assistance. When public assistance eligibility is established at Rikers, patients

will receive an initial check at discharge. Otherwise, patients who report to their

community program must wait at least 6 weeks for a check after completing

their public assistance application. In the meantime patients may lack subway

or bus fare to attend the clinic, especially when it is in a two-fare zone.

Medicaid has a provision for issuing “car fare” vouchers for medical visits, but

the authorization procedure is tedious. In general, patient noncompliance is a

serious barrier to retaining KEEP patients in treatment; in addition, the

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institutional structures are not especially conducive to serving addicts who often

are ambivalent and disorganized. The less “user-friendly” the system, the more

likely addicts are to use red tape as an excuse to “give up.”

PRELIMINARY RECOMMENDATIONS

Adequacy and stability of funding for both the Rikers and the community KEEP

components are essential to maximize the potential of the program. Some

programmatic reorientation also should be considered. Currently, drug abuse

treatment services at Rikers are dichotomized between (1) methadone

maintenance for heroin users (minimal counseling support) and (2) fairly

intensive therapeutic community-style treatment for primary cocaine users. It

would be reasonable to introduce a cocaine treatment component for the heroin

addicts as well, since their use of cocaine and heroin are often at similar levels.

This should be coordinated with continuing cocaine use treatment in community

methadone programs. Clearly, cocaine use is a critical problem for the

methadone modality that is not limited to the KEEP population, but exactly how

this should be addressed in the absence of well-tested outpatient cocaine

treatment models requires more thought, discussion, and research.

Aside from the cocaine issue, the KEEP concept can be made more viable by

continuing to increase the “user-friendliness” of the program. This already has

begun, for example, through public assistance and Medicaid workups for some

KEEP patients at Rikers and community programs to increase supportive

services to KEEP patients in response to their demonstrable needs.

Unfortunately, increased funding is required to maintain and expand these

efforts, but New York State is in a budget crisis. A residential treatment option

is especially important because homelessness is a pervasive problem, in

addition to the street drug culture that most KEEP participants again encounter

after release. Community KEEP originally was envisioned as a limited-service,

transitional program leading to regular methadone maintenance or other longterm treatment, but it is now clear that addicts released from jail require more

rather than less assistance and support than other applicants for treatment if

there is to be any hope of retaining substantial numbers in community

treatment.

KEEP patients who receive a complete physical at Rikers within 3 months

before admission to a community methadone program are not required under

Federal or State regulations to undergo a new physical. If copies of the Rikers

KEEP medical records were transmitted routinely to community programs for

such patients, one of the main reasons for administrative discharge of KEEP

patients would be reduced. This would require clerical assistance at Rikers but

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would save reexamination expenses at the community programs. Of course, a

program still could require the patient to undergo a new physical.

Finally, an opportunity probably is being lost to use the criminal justice process

as leverage to encourage ambivalent addicts to enroll in community drug

treatment. Currently, convicted inmates usually serve their full sentences at

Rikers with “good time” deducted and are released without conditions. It would

seem sensible to consider early release on probation with the condition that

KEEP participants report to and remain in long-term drug abuse treatment at

least for the duration of their sentences. This would provide programs with an

opportunity to engage these addicts; prior research has indicated that

compulsory treatment can be useful (Anglin 1988; Maddux 1988; Hubbard et al.

1988).4

NOTES

1.

2.

3.

4.

Narcotics addicts with multiple incarcerations might be detoxified more than

once annually. Addicts who have completed withdrawal before admission

to Rikers (e.g., while being held in a borough detention facility) are ineligible

for detoxification.

New South Wales, Australia, has a prison-based methadone program, and

physicians in the Netherlands are allowed to prescribe methadone for

inmates. However, KEEP serves by far the largest number of narcotics

addicts.

At this time the reporting rates do not include individuals who after release

may have entered a community methadone program that was not their

designated program or a drug-free treatment program. However, a sample

of the followup interviews indicates that these are infrequent events.

Transfers to another program, whether methadone or drug-free, after

reporting to the designated program are included in the retention statistics.

A conditional release procedure is being established at the New York City

Department of Correction, but it is uncertain whether enrollment in

methadone maintenance will constitute an acceptable condition of release.

REFERENCES

Anglin, M.D. The efficacy of civil commitment in treating narcotic addiction. In:

Leukefeld, C.G., and Tims, F.M., eds. Compulsory Treatment of Drug

Abuse: Research and Clinical Practice. National Institute on Drug Abuse

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Research Monograph 86. DHHS Pub. No. (ADM)89-1578. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1988. pp. 8-34.

Ball, J.C.; Rosen, L.; Flueck, J.A.; and Nurco, D.N. The criminality of heroin

addicts when addicts and when off opiates. In: Inciardi, J., ed. Drugs-Crime

Connection. Beverly Hills, CA: Sage Publications, 1981. pp. 39-65.

Centers for Disease Control. HIV/AIDS Surveillance. Rockville, MD: National

AIDS Information Clearinghouse, April 1990.

Chaiken, M.R., and Chaiken, M. Crime rates and the active offender. In:

Wilson, J.Q., ed. Crime and Public Policy. New Brunswick, NJ: Transaction

Books, 1983. pp. 11-29.

Chaisson, R.E.; Baccheti, P.; Osmond, D.; Brodie, B.; Sande, M.A.; and Moss,

A.R. Cocaine use and HIV infection in intravenous drug users in San

Francisco. JAMA 261(4):561-565, 1989.

Goldsmith, D.S.; Hunt, D.E.; Lipton, D.S.; and Strug, D.L. Methadone folklore:

Beliefs about side-effects and their impact on treatment. Human

Organization 43(4):330-340, 1984.

Hammett, T.R. 7988 Update: AIDS in Correcfional Facilities. Washington, DC:

U.S. Department of Justice, June 1989.

Hubbard, R.L.; Collins, J.J.; Rachal, J.V.; and Cavanaugh, E.R. The criminal

justice client in drug abuse treatment. In: Leukefeld, C.G., and Tims, F.M.,

eds. Compulsory Treatment of Drug Abuse: Research and Clinical Practice.

National Institute on Drug Abuse Research Monograph 86. DHHS Pub. No.

(ADM)89-1578. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988. pp. 57-80.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh, E.R.;

and Ginzburg, H.M. Drug Abuse Treatment: A National Study of

Effectiveness. Chapel Hill and London: The University of North Carolina

Press, 1989.

Innes, C.A. Profile of State Inmates. Bureau of Justice Statistics Special

Report. Washington, DC: U.S. Department of Justice, 1988.

Johnson, B.D.; Goldstein, P.J.; Preble, E.; Schmeidler, J.; Lipton, D.S.; Spunt,

B.; and Miller, T. Taking Care of Business: The Economics of Crime by

Heroin Abusers. Lexington, MA: Lexington Books, 1985.

Kolar, A.F.; Brown, B.S.; Weddington, W.W.; and Ball, J.C. A treatment crisis:

Cocaine use by clients in methadone maintenance programs. J Subst Abuse

Treat 7:101-107, 1990.

Kreek, M.J. Health consequences associated with the use of methadone. In:

Cooper, J.R., ed. Research on the Treatment of Narcotic Addiction: State of

the Art. National Institute on Drug Abuse Treatment Research Monograph

Series. DHHS Pub. No. (ADM)83-1281. Rockville, MD: Alcohol, Drug

Abuse, and Mental Health Administration, U.S. Public Health Service, U.S.

Department of Health and Human Services, 1983. pp. 456-491.

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Lange, W.R.; Snyder, F.R.; Lozovsky, D.; Kaistha, V.; Kaczaniuk, M.A.; and

Jaffe, J.H. Geographic distribution of human immunodeficiency virus

markers in parenteral drug abusers. Am J Public Health 78(4):443-446,

1988.

LaPorte, C. “Key Extended Entry Program at Rikers Island (KEEP).” Paper

presented at the American Correctional Institute Winter Conference,

Phoenix, AZ, 1988.

Maddux, J.F. Clinical experience with civil commitment. In: Leukefeld, C.G.,

and Tims, F.M., eds. Compulsory Treatment of Drug Abuse: Research and

Clinical Practice. National Institute on Drug Abuse Research Monograph 86.

DHHS Pub. No. (ADM)89-1578. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1988. pp. 35-56.

Magura, S.; Siddiqi, Q.; Freeman, R.; and Lipton, D.S. Cocaine use and helpseeking among methadone patients. J Drug Iss 21:629-645, 1991.

Marmor, M.; Des Jarlais, D.C.; Cohen, H.; Friedman, S.R.; Beatrice, S.T.;

Dubin, N.; El-Sadr, W.; Mildvan, D.; Yancovitz, S.; Mathur, U.; and Holzman,

R. Risk factors for infection with human immunodeficiency virus among

intravenous drug abusers in New York City. AlDS 1:39-44,1987.

National Institute of Justice. DUF: 1988 Drug Use Forecasting Annual Report.

Washington, DC: U.S. Department of Justice, 1990.

New York City Department of Health. AIDS Surveillance Update. New York:

Department of Health, March 28, 1990.

New York State Department of Health. AlDS in New York State. Albany, NY:

Department of Health, 1989.

ACKNOWLEDGMENTS

The study was funded by National Institute on Drug Abuse grant DA-05606 in

cooperation with the New York State Division of Substance Abuse Services.

The points of view or opinions expressed herein do not necessarily reflect the

official positions or policies of the U.S. Government, New York State

government, Narcotic and Drug Research, Inc., or any cooperating institution.

AUTHORS

Stephen Magura, Ph.D.

Deputy Director of Research for Treatment and Prevention

Andrew Rosenblum, Ph.D.

Senior Project Director

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Narcotic and Drug Research, inc.

11 Beach Street

New York, NY 10013

Herman Joseph, B.A.

Senior Research Scientist

Bureau of Research

New York State Division of Substance Abuse Services

55 West 125th Street

New York, NY 10027

210
Management of the Drug-Abusing

Offender

John Gregrich

“The world has not suffered from the absence of noble aims anywhere nearly

as much as it has suffered from the absence of means for realizing ends that

are prized in an abstract or sentimental way.” —John Dewey

INTRODUCTION

This chapter provides a respite from the formal presentation of findings that

generally characterizes National Institute on Drug Abuse (NIDA) publications.

Other chapters in this volume cover the relevant research eloquently, whereas

this chapter raises rather than answers more questions and draws heavily on

the work and ideas of so many others that it is sometimes difficult to determine

where one person’s ideas begin and another’s end. Furthermore, as most

program managers know, the brief note transmitting a major report often cuts

to the real heart of the matter, revealing areas of certitude as well as nagging

questions on which the formal methodology is silent.

After numerous futile attempts to organize and speak about this topic, one is

reminded of the views of Schumacher (1978) and Percy (1977): Being stuck

is a privileged, prehypothesis state in which one’s ideas become visible and

are potentially the objects of thought and not merely its instruments. Sorting

through case management matters of significance to offender drug treatment

starts with a list that would probably differ little from researcher to program

developer to program administrator: offender/client assessment, essential

treatment services and programs, linkage within the criminal justice system

and between it and other social service systems, program development

prerequisites and program maintenance requirements, human resources,

staff training, performance standards, management information requirements,

incentives/sanctions, funding, public information, and evaluation.

Program and case management are the essence of such a list. The irony is

that the substantive steps generally identified as important and requiring

management seldom bear a direct relationship to performance. Program

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developers are inclined to attack measurable problems by creating an “ideal”

program concept from which program administrators may immediately excuse

themselves, given resource and time constraints. In other words, the “answers”

to the perceived problems are drawn from theory and common sense and not

from concrete experience. Of corollary significance, the solid information

required to garner support for such answers is seldom provided by existing

research.

A WORKING DEFINITION

Offender case management exists to inform decisions. To do so, it should

include a formally disciplined set of continuing steps by which sufficient,

relevant information about a particular individual is gathered, analyzed,

revised, employed, and documented and then is made available for use by

others. The most specific contribution of offender management is the clear

expression of the extent and nature of the individual’s problem at any specific

time; the corollary contribution is the response to this understanding, which

ideally is the identification of the most appropriate action or set of actions.

Offender case management assumes that there is at least basic consensus

that intervention beyond simple retribution has value and that available

interventions will have a positive impact. That is, case management assumes

that the findings presented in other chapters and summarized below are valid

and significant. Offender case management also assumes that there is an

infrastructure-that treatment programs exist and that someone is charged to

make decisions, apply sanctions, employ threats, and assess progress. Finally,

offender intervention management assumes that this basic infrastructure can be

built on and refined to handle the growing number of cases and to gather from

disparate sources the kinds of relevant, dynamic information required to make,

assess, and revise decisions.

To the extent that these assumptions are not warranted in a given jurisdiction,

decisions will be episodic and their bases obscure. In such settings, which

are not uncommon, offender management efforts, by making information

available, may “create” new decision responsibilities. In so doing, offender

management agencies risk being ignored or worse. For example, in some

jurisdictions, decisionmakers have rejected the development of drug testing

programs to avoid being confronted with new information for which they have

no established response.

TRENDS AND ATTENTION

For the next decade, offender management programs will be required

to address both the impact of drugs on society and the organizational

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consequences of various national responses to the impact of drugs on

society. Crowding of institutional and community programs is at present

the most obvious result of these combined forces. Programs, and their

consequences, can be inferred from the forces that are at work.

The recent reports of the Office of National Drug Control Policy (ONDCP)

(1989, 1990, 1991) offer a compendium of the problems and approaches

on which a degree of consensus is emerging. In offering priorities, this Office

has served to predict and to influence public actions for the immediate future.

Enforcement has been the most pervasive priority: street-level enforcement,

multijurisdictional task forces, sophisticated investigation techniques,

vigorous prosecution, mandatory minimum sentences, increased Federal

personnel across branches, and civil commitment. The degree to which

these enforcement initiatives are successful is the degree to which institutional,

community, and case management programs will experience increases in

their caseloads.

Treatment programs also are supported directly within the priorities, albeit

with a clear concern regarding their effectiveness. In addition to the call for

an increase in treatment resources, which includes treatment for criminal

justice populations, there is the repeated call for evaluation of current treatment

methods, of user/treatment matching, and of ‘what works” in programs and

approaches. Given this attention and increased resources, treatment programs

should be prepared to offer a public accounting of effectiveness at a level of

detail not previously required of them.

Offender case management was not addressed as a discrete matter until

the third report (Office of National Drug Control Policy 1991), although it

was implied in some priorities and required for the accomplishment of others.

Initially, drug testing was emphasized, alternative sentencing encouraged,

data collection urged, and coordination-including the submission of State

treatment plans-recommended. Given the specific inclusion of Treatment

Alternatives to Street Crime (TASC) (see Weinman, this volume) in the 1991

“National Drug Control Strategy” report, offender case management will be

seen as more important to the disciplined implementation of the national

strategy. However, case management programs such as TASC should remain

sensitive to their relative organizational visibility (to why they are often an

afterthought) and to their challenge to communicate case management

principles clearly, early, and continually.

Viewing the published national strategy as a harbinger, case managers working

with and within criminal justice agencies can anticipate an increase in drug

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testing, an increase in new programs and/or new program titles, an increase

in the concern of their colleagues for their own safety while working with

serious offenders, and an increase in demands for surveillance, accountability,

evaluation, and innovation.

Finally, offender case management programs can anticipate an increase in

public attention to and expectations of their efforts, coupled with an increase in

budget resources that might bear little relationship to increased expectations.

In this regard, it is important to note that certain obstacles to progress will

accompany the trends that are taking shape.

TRENDS AND OBSTACLES

Current Window of Importunity

Case management draws episodic and fleeting attention from resource

allocators and from line agencies. It is a crisis-related attention, which grows

in response to an unacceptable level of anxiety. When there are too many

bodies to handle and/or the problems they present are too complex and when

the system is not coherent or not in control (perhaps not a system), entities

such as ONDCP and TASC programs are created to put the Nation back on

track. Now is a time of such attention.

Case managers should seize the opportunity to make some progress and

accept the fact that there are systemic and circumstantial forces that mitigate

against continued attention. Circumstantially, the intensity of attention will be

inversely proportional to the progress made; the attention will last as long as the

perceived crisis. Systemically, offender case management cannot command

continuing attention and support because it lacks established orthodoxy,

effective political organization, effective professional organization, a national

perspective, and a natural organizational home. The circumstantial matters

are beyond our influence; the systemic matters should be the national agenda

for action.

The Systemic Problem of Organization

The drug-abusing offender represents a management problem for the criminal

justice system, a problem so basic that it invites reflection on the origin and

limits of the term “criminal justice system.” An intellectual construct, developed

by systems engineers decades ago to invite a comprehensive perspective on

the problems of crime and justice, this term is now an unexamined part of the

public policy vocabulary. This synthetic, postfact, descriptive term is used as if

it were definitive, as if real agencies in real time were formally charged to view

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themselves as part of a greater substantive entity, to which they were

accountable and for which they share joint social accountability with other

system members. In fact, these system members function under separate

budgets, have different organizational missions, and in some cases, are

part of constitutionally separate branches. So, when public officials speak

of the criminal justice system-as they must when addressing offender case

management-they are always speaking theoretically or prescriptively. Finally,

when case management programs accept the responsibility for making the

system work, they are courting disaster.

The Systemic Problem of Authority

“Authentic authority [and its exercise] has three bases: social position,

expertise, and love. If any of these bases is missing, what is being exercised

is something less than authentic authority.“- Ancient Christian Formulation

When drug czars, TASC programs, and, to some extent, pretrial service

agencies and probation and parole agencies get serious about offender case

management, they have overstepped their bounds. They are clearly on the turf,

and often on the toes, of line administrators. They are free-floating executives

without a sense of permanence, without direct line authority, and without control

over the quality of the services they would manage. Their authority is subtle

and fragile, based in large part on their continued demonstration of expertise

and goodwill. Indeed, resistance and competition from their peers are more

likely to result from their excellence than is appreciation. TASC is a useful

example. Some insight into the most basic requirements of authority for case

management can be gained by asking certain questions of this program, which

began as Treatment Alternatives to Street Crime and which has evolved into

Testing, Assessment, Supervision, and Control.

Is TASC (i.e., drug-dependent offender case management) a discrete

and necessary program or an extra safety valve to protect against the

underperformance of probation and parole (or pretrial services or

institution-to-community transition) functions? Is there so fundamental a

difference in the nature of criminal justice agencies (such as probation)

and social service agencies (such as drug treatment) that they cannot

understand each other or effectively utilize each other’s strengths without

an intervening agent?

An answer in the affirmative, at least for the foreseeable future, results in

additional questions. What is the essential expertise of this agent? What

does experience with similar agents reveal about the organizational placement

of this agent? For example, does the advocate/architect role of the entry-level

family practice physician vis-a-vis medical specialists offer a model?

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These are questions worthy of significant reflection on the part of jurisdictions

that would take case management seriously. In jurisdictions where TASC

or TASC-like programs have been established by statute, they are able to

work effectively as peers with probation and other criminal justice agencies.

In jurisdictions where they are not so established, they face the requirement

of continually pleasing many masters (i.e., funders and funding supporters)

and continually demonstrating substantial but nonthreatening expertise.

The Systemic Problem of Shared Understanding

“All but the most naive (or politically inclined) social scientists concede that the

scientific study of human behavior cannot replace ethical judgment and political

wisdom.” —James R. Kelly

Because there is no unified or unifying professional voice for case

management, there is virtually no direct case management research carried

out in criminal justice settings and very little synthesis of the relevant findings

of other research.

Much of what is said with relative confidence about offender management is

borrowed from drug treatment research. It appears to be related. In fact, the

problem goes much deeper than the focus of research. By gaining preeminent

authority as the means to certitude, scientific methods in general and research/

evaluation design in particular have conspired to erode our sense of confidence

in our own observation of the content and outcome of offender intervention

programs. When researchers and other scientists are at non sequiturs with

treatment program providers in attempts to discuss the content and impact of

treatment programs, Walker Percy’s essay “The Message in the Bottle” (1977)

comes to mind as a bridge to understanding. In this essay, Percy distinguishes

the canons of acceptance for “knowledge” from those for “news.”

Knowledge has a timeless quality. To become knowledge, information must

be general, repeatable, and affirmable. The hearer accepts it or rejects it. It

is most elegant when it is most general. For example, E=MC2 Or, to offer

a more pedestrian example, if the statement “lead melts at 300 °C” is to be

accepted as knowledge, it must do so for anyone, anywhere, at any time.

News is of a different order; it implies a call to action. It is immediate, personal,

and not subject to affirmation or refutation at the point that it is delivered. The

hearer heeds it or ignores it. The statement “On average in the United States,

35.7 hotel fires involve fatalities each year” can be tested against the canons for

acceptance for knowledge. The statement “There is a fire in this hotel; I know

the way out, please follow me” invites a different mental process. The canons

of acceptance for news, offered by Percy (1977), are three: Is it relevant to me?

Is it possible? Does the demeanor of the news-giver invite trust?

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This distinction between knowledge and news does not exactly fit a discussion

of drug treatment; over time, drug treatment will indeed have a substantial body

of irrefutable knowledge. However, successful drug treatment will always

involve a very personal conversion process. And, for the interim, treatment

providers will be approaching resource allocators for support of programs, in

an arena fraught with incomplete and often conflicting outcome information.

The demeanor of the “news-giver” in such an environment takes on great

importance and may determine whether his or her call will be heeded or

ignored.

Related Circumstantial Problems of Episodic Response, Oversell, and

“Innovation”

“Government works best when it is a little dull.“-Warren Rudman

Intolerance of crime, limited confidence in the deterrent and rehabilitative

effectiveness of nonpunitive interventions, and limited social satisfaction

with criminal sentences that appear to fall short of deserved retribution have

resulted in a sharp increase in the use of incarceration as the preferred public

response to crime. This social preference is reflected by legislatures and

judges imposing a variety of sentence enhancements. It has not as yet been

reflected in a proportional expansion of prison capacity or in correctional

budgets because an extended period of economic uncertainty has resulted

in fiscal austerity for virtually all social programs.

In essence, public officials have decided on the face validity of retribution

and incapacitation offered by incarceration rather than the promising but

less certain approach to rehabilitation and deterrence offered by community

programs. Irony creeps into the equation, however, as social conservatism is

layered on fiscal conservatism; the least complicated response to crime is also

the most expensive response during a period when fiscal growth has been

curtailed by choice and circumstance. Crowded prisons and jails as well as

increased probation and parole caseloads are among the results, sending

program managers scrambling for interim solutions.

A dysfunctional and potentially destructive byproduct of this scramble is the

de facto adversarial relationships that can develop among agencies attempting

to avoid the consequences of crowding. Probation and parole can be viewed

by State correctional authorities as population control devices rather than as

sanctions in their own right. (One reflection of this is the tendency to refer to

offender “surveillance” rather than to offender “supervision.“) Community

caseload capacities are viewed as highly elastic and are used, through pretrial

diversion and early release from institutions, to take the pressure off of crowded

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institutions. Probation and parole, which have done even less well budgetarily

than their institutional counterparts, respond to this growth in size, complexity,

and seriousness of caseload population by violating (i.e., returning to the

institution due to a technical violation of parole or probation conditions) as

many offenders as possible as quickly as possible. Thus, probation and

parole condition violators become an increasingly larger proportion of the

prison admission population. Offender movement rather than offender

management has primary claim on agency attention and creative energies

It has been suggested that some jurisdictions avoid court-ordered population

caps by keeping the maximum number of arrestees, defendants, and offenders

in transit on buses between police stations, courtrooms, and corrections

facilities (Friel 1990).

Other significant byproducts are the oversell of certain programs as

comprehensive answers and the promise of innovation-as-solution pursued

by policymakers and program managers. An example of the former is found

in the growth of so-called intensive supervision programs. It appears that,

having been invited to the policy table, advocates of community corrections

are attempting to keep their chairs by promising more than can be delivered.

As evaluators have noted (Petersilia 1990; Byrne 1990), intensive supervision

programs differ considerably from site to site, while the advocates of these

programs make general claims for them (e.g., they will reduce prison crowding,

increase public protection, rehabilitate the offender, demonstrate the potential

of probation, and save money). Data on several programs, in relationship to

each of these objectives, are now being collected and reviewed. One can only

hope that the effective elements of such programs will be identified and will

survive the coming period of evaluation and accountability.

An example of the innovation-as-solution approach is the growing popularity

of elusive terms such as “intermediate sanction.” A number of researchers and

practitioners are proponents of intermediate sanctions. Their position has been

expressed recently by Morris and Tonry (1990), who contend that

essentially we are too lenient and too severe with convicted

offenders-too lenient with many on probation who should

be subject to tighter controls in the community, and too

severe with many in prison and jail who, if under adequate

supervision, would present communities with no serious

threat . . . Between [prison and probation] is a spectrum of

intermediate punishments that are hardly used.

The logic of the statement is evident. On a more modest scale, TASC

programs have pursued graduated sanctions in the management of offenders

for many years. A representative list of the sanctions usually mentioned,

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roughly in the order of present utilization, would include drug and/or alcohol

monitoring, curfew/house arrest, community service, electronic monitoring,

restitution, team supervision, mandatory referrals, probation fees, split

sentence/shock incarceration, court costs and fees, day reporting, money

fines, day fines, and civil penalties.

Pursuing an intermediate sanctions policy can produce considerable

tension, especially among offender case managers. Whether this tension

will be creative depends largely on the extent to which disciplined program

development will be possible in a political environment seeking quick answers.

The first problem that must be confronted is the tension among the so-called

traditional goals that guide the application of sanctions: retribution, deterrence,

incapacitation, rehabilitation, and restitution. There is a point at which the

focused pursuit of any one of these goals may threaten to erode progress

on the others. Failure to distinguish among these goals and establish the

preeminent goal(s) up front can only result in dysfunctional conflict. Two

major camps are already forming. On the one hand are those who focus

primarily on the offender’s crime and who view intermediate sanctions as a

shopping list of discrete punishments. They tend to favor retribution as a

complete and satisfying response and to focus on what society should do in

response to criminal acts. This presents no problem of logic or expectation

unless or until they begin to attribute deterrent or rehabilitative effect to

programs that are retributive.

On the other hand are those who focus primarily on the offender’s eligibility for

intermediate sanctions as a clear indication that the offender probably will not

be incarcerated or be released reasonably soon if incarcerated. They tend to

have little faith in the deterrent value of isolated or long-term punishments, and

they are inclined to mold intermediate sanctions to ensure intensive monitoring

and to attempt behavior change. They tend to focus on what the offender will

do upon release if effective intervention has not been employed while the

offender was in custody. The intellectual difference between the two camps

is more apparent than real; the emotional difference and its impact on their

ability to work together are quite real.

The second problem relates to the steps, resources, and time required to

develop a program. Some advocates of intermediate sanctions seek a

“menu of options” from which the criminal justice system can select sanctions.

The implicit assumptions of the “menu” approach are that a selection decision

is the only requirement and that sanctions will emerge as effective operating

programs in response to that decision. This relates to the first problem

addressed. If the only objective is the selection of a discrete act of retribution

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for a specific offender at a specific time, then a decision may be sufficient. If

the objective is to confound, defeat, and ultimately change the manipulative,

recalcitrant, recidivist behavior of the drug-dependent offender, an isolated

decision is not sufficient. Program development to provide a highly structured

system of graduated sanctions and interventions and an unbroken supervisory

contact, with no apparent exits other than acceptable behavior, does not flow

from a sentencing decision. Such an infrastructure will take a good deal of time,

resources, and hard work.

The third problem relates to the resources required to conduct a program.

Because of the inherent logic of their basic position, advocates appear to

hold the view that intermediate sanctions should, can, or will be developed

independent of considerations of resource constraints. However, even a

cursory view of the list presented above indicates that virtually all intermediate

sanctions cost more than so-called simple probation; some, such as boot camp,

cost more on a per-day basis than traditional incarceration (MacKenzie et al.

1989, 1990; MacKenzie and Parent 1991). If the objective is to increase

surveillance and control (and public safety), it will not be accomplished with

caseloads of 200. Since current probation budgets often result in caseloads

of 200, the choice is between increased spending and decreased expectations.

It is incumbent on offender case managers to provide solid information in this

regard.

The focus on intermediate sanctions is representative of the growing social

demands, which offender case managers cannot avoid or put off with passive

resistance. The only responsible approach will be to work with policymakers

on these efforts and guide them to distinguish between programs and

technologies, to avoid the dangling comparatives of oversell (e.g., “cheaper,”

“more intense”), and to avoid the use of undefined terms (e.g., “traditional

probation”) as fixed givens and universally understood terms of art.

AN AGENDA FOR AN AGENDA FOR ACTION

“When in doubt, do the right thing.” —Dean Acheson

Although the problems and obstacles are systemic and circumstantial, the

response must be systemic. If permanent improvements are to be built in

the midst of change, those elements and actions that transcend the polemic

tension between punishment and healing must be identified. For the

foreseeable future, the responsible course in this regard lies in the use of

three available instruments: research and evaluation, technical assistance

and training, and management information systems. The most productive

foci for these instruments are operational performance standards-for

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offender management programs and for the related direct service programs—

and program outcome measures.

Research/Evaluation

Abraham Caplan noted that most human beings (and all methodologists) are

subject to “the law of the instrument”; that is, you give a small boy a hammer,

he will discover that everything within reach requires pounding.

Researchers and, to a greater extent, evaluators will be wielding considerable

influence over the next few years. Because of this and because incurable

optimism indicates that they will rise to this challenge with the humility of

authentic scientists, the bulk of the following recommendations is directed

to them.

More Attention to and Discussion of Substantive Program Detail Are

Required. In the coming period of accountability, when programs will rise or

fall in response to evaluation findings, responsible researchers must take

particular care to avoid designing ignorance into their methodology. They can

maintain the necessary disinterest and distance, while avoiding this pitfall, by

designing efforts that define both the elements of operational performance

and the measures of outcome. Terms such as “drug treatment,” “traditional

probation,” “probation contact,” and “successful completion” are not terms of

art and are subject to a variety of interpretations. Responsible research and

evaluation designs will define them in sufficient detail to allow for credible,

comparative analysis.

The costs of not defining key terms are significant, in terms of contribution

to knowledge and in terms of impact on the programs studied. A couple of

examples should serve to illustrate. A major city study compared the impact

on drug-using arrestees of drug testing and monitoring with that of drug

treatment and found the former to be more effective (Wish and Gropper 1990).

The finding appeared significant until it was learned that although the drug

treatment provided was designed for opiate abusers, primarily methadone

maintenance, the primary drugs of choice of the arrestees were phencyclidine

(PCP) and cocaine.

A somewhat more subtle example is found in a recently concluded study

(J. Petersilia, personal communication, January 1990) that compares

the impact of intensive supervision programs (ISPs) with that of other

probation programs. The evaluation presents “number of contacts” as one

of the measures in comparing the impact of the programs, although among

the evaluator’s caveats is the stated inability, given the data source, to

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distinguish between the programs in terms of the nature or quality of the

contacts. Among the other caveats and qualifiers in the study is the conclusion

that the specific elements of ISPs that are effective have not been established

and that the ability to ensure program implementation in accordance with

program design is uncertain. Such observations are significant and relatively

common; however, they often are viewed as tangential to the substance of the

report. In fact, they are the heart of the matter; they are the reasons why

evaluations are often inconclusive: and they are most often related to the quality

of program design and execution.

To counter this, responsible stubbornness will be an essential characteristic

of evaluators, given their potential influence over the next decade. Holding up

the promise of credible findings as the incentive, evaluators should demand

early access to program design to ensure adequate definitional work and data

collection procedures. In this manner, the questions to be addressed will

emerge more clearly for the evaluator, the program manager, and those who

will use the evaluation findings to inform their decisions. Evaluators should

probe, rather than accept, general terms such as “treatment” to make visible

their substantive content. Evaluators should make visible the operational

standards implied in program elements; if a caseload of 20 or less is essential

for the intensive provision of the constituent services of ISPs, this should

be stated clearly up front. There is a creative tension in such an iterative

process if it is conducted early enough. A program that allows for process

and outcome evaluation is, by definition, a well-designed program. A welldesigned evaluation can determine early on whether a program can be

evaluated. If it cannot be evaluated, there is reason to question whether

it is a program and whether it should be conducted at all.

Impressions and Insights Should Be Shared and Sought. The scientific

study of human behavior should seek, but not be limited to, statistically

significant findings. These often will be few and highly qualified. Indeed,

statistical principles will not tell the evaluator where to look or what to count.

At times, findings related to groups too small to report on invite disciplined

attention, thought, and discussion. The ISP study discussed earlier found

lower recidivism rates for a group that had received drug treatment but was

too small to influence study statistics (Petersilia 1990). Similarly, some years

ago, a National Institute of Justice research utilization committee addressed a

study of the short- and long-term impact of crime victimization in New York.

One obscure finding, buried in the report, noted a small group who stated that

their lives were better after the victimization than before. Additional study of

this group indicated that they shared in common the impression that the police

had gone out of their way to help them. This information was not statistically

significant, indeed it was a small departure from a Many of pain and frustration,

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but it was of considerable use to those designing the critical elements of a

victim assistance program.

In addition to inviting review and comment on findings, researchers and

evaluators would do well to seek other observations and insights from

practitioners. For example, in the midst of widespread attention on the

importance of assessment and offender-treatment matching, there appears

to be an emerging consensus among practitioners that the most important

match is that between the individual therapist and the individual offender.

Efforts by researchers to provide a disciplined study of this matching would

be of immediate assistance to those trying to accomplish it.

Old Methods Need To Be Refined, New Methods Employed, and New and/

or Interim Language Embraced. Large-scale, long-term studies of treatment

and case management should be conducted as the surest way to avoid

methodological pitfalls (Fletcher and Tims, this volume). However, in the

interim, researchers and evaluators are faced with the need to extract

significant findings from small samples and subsamples and to assess

outcomes for programs designed to serve a multiplicity of objectives.

Statistical power analysis offers some promise in helping avoid collapsing of

subsamples into a heterogeneous hodgepodge to enable us to speak with

statistical, if not literal, significance. Survival analysis and related techniques

will facilitate the analysis of complex questions with the specificity warranted,

adding positive, negative, and interim measures to fixed, flat, and final

measures such as recidivism.

In addition to the continued refinement of existing quantitative methods,

some attention should be given to the reality that coruscates through the

testimonial evidence that is so much a part of drug treatment. To this end,

evaluative thinking might be strengthened with the inclusion of some systematic

anecdotal research and some ethnographic research to enable evaluators to

speak qualitatively with more precision. Successful drug treatment involves a

highly personal and individual conversion process and does not yield easily to

the instruments of science.

Akin to Percy’s distinction between knowledge and news, is the “Birmingham

Post-Herald” account of William Bennett’s reaction to his site visit with

Alabama’s prison treatment program participants: “More than what they

said was how they said it ...” (Joynt 1990). “They stood up straight and they

looked me in the eyes as they spoke. Heck, two-thirds of Congress won’t look

me in the eyes” (Nation 1990).” Policymakers are moved by such experiences.

Researchers ought to help them develop the language to address it and the

means to assess its essential content and validity.

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Some Practical Flndings and Observations

Treatment and Coercion Work Together. Research has concluded that

substance abuse is treatable, even for the offender population, and that

appropriate actions by the criminal justice system can foster its effectiveness.

Major longitudinal evaluations have found drug treatment effectiveness to be

directly related to length of stay in treatment. Treatment for drug-dependent

offenders has been found to be most effective when there is direct criminal

justice involvement. Researchers have found that the threat of criminal justice

sanction motivates offenders to enter treatment and, perhaps more important,

motivates them to stay in treatment for a period sufficient for behavior change

(Leukefeld and Tims 1988).

Thus, compulsory treatment appears to be effective, and the criminal justice

system appears to be uniquely equipped to get people into treatment and to

keep them there for a period sufficient to allow for positive change. Despite

the apparent symbiotic relationship, treatment and criminal justice will remain

strange bedfellows.

The criminal justice system is charged very directly by society to fix blame, to

prove guilt beyond a reasonable doubt, and to administer the consequences

set by society for unacceptable behavior. The judgmental nature of this

mandate is, on its face, the antithesis of therapy; yet the threat of criminal

justice sanction functions to motivate many to enter and stay in treatment.

Drug-Abusing Offenders Are Harder To Treat Than Mainstream Members

of Society. Information from treatment evaluations is essential to management

of intervention with the drug-abusing offender, but it is not sufficient. Most

offenders lack the attributes on which traditional treatment approaches have

relied: stable employment and the skills to maintain it, permanent residence

with its sense of place and belonging, significant material possessions and the

stake in society that they reflect, strong family ties and the corollary sense of

responsibility and support, and the kind of social ties that would offer positive

role models and peer pressure. To this must be added an equally significant

litany of attributes possessed by most drug-abusing offenders: a set of life

patterns and value systems, often called a “criminal mentality,” which is based

on an orientation to reality that is profoundly different from that of mainstream

society, a strong personal stake in maintaining this mentality, a strong personal

stake in maintaining contact with peers who reinforce it and glamorize it, and a

strong personal stake in resisting information that would question it.

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Treatment and/or Intervention Programs for Drug-Abusing Offenders Must

Take Full Cognizance of the Overlapping Forces That Are Presented by

Offenders. Programs that seek to alter behaviors that constitute the identity

of these offenders will invariably be met with hostility and with a deep-seated

motivation to maintain this glamorized sense of self as a daring adventurer

battling against the victimization visited upon him or her by society. To be

effective with a population of chronic, drug-abusing offenders, treatment

programs must focus not merely on the drug-abusing behavior but also on

the interlocking web of deviant thought and behavior patterns.

Successful Treatment Programs for Drug-Abusing Offenders Share

Certain Characteristics With All Successful Treatment Programs. They

are based on an established theory, grounded in empirical evidence, and

focused on a population assessed as appropriate for the intervention dictated

by the theory. Successful programs are specifically designed to implement

the adopted theory through steps of sufficient duration and intensity to effect

a lasting change in behavior and are supported by periodic drug testing to

maintain program integrity. They are conducted by staff members who have

received adequate training and who continue to receive adequate supervision,

and they provide for the continued collection and analysis of program data to

ensure both process and impact evaluation.

Intensive Surveillance Produces Results. Frequent contacts with the

offender and collateral contacts with employer, family, and positive peers

increase the opportunity for detection of noncompliance and increase the

opportunity for preventive or remedial intervention. And, in a related matter,

drug testing of institutional and community offender populations-when

conducted in accordance with a policy of specific sanctions-will reduce

drug use in those populations.

Effective Offender Management Must Be Sufficiently Organized and

Orthodox To Counter the Criminal Attitude and Manipulation Skills of

the Offender and To Utilize the Disparate Resources of the Community.

Research and program experience combine to indicate that effective

intervention with the drug-abusing offender is greatly dependent on the

extent to which it:

Occurs early (in the drug/crime career and in the criminal justice process)

Is based on a thorough assessment of offender characteristics

Is rigorous, formal, and substantial

Maintains unbroken contact with the offender

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The assessment that informs offender referral and management decisions

should include the status of the criminal career, the status of the drug-abusing

career, and the stakes in social conformity presented by each case.

Measures of Program Effectiveness Can Properly Reflect and Contribute

to the Design of the Intervention Employed. Recidivism rate will properly

continue to be a basic indicator of program effectiveness with criminal justice

populations. However, given the potential impact of even small percentage

changes when applied to large populations, more refined measures are needed

to maximize program effectiveness. Such measures as drug-free and/or crimefree days while under supervision, relative time to rearrest, and days employed

will provide better information on the effect of interventions on chronic behavior.

Furthermore, the periodic application of assessment instruments to matters

subject to change-dynamic measures such as drug use or intellectual

comprehension-are essential to tracking progress.

Interim and Long-Term Measures Have Shown That Relapse Is Relatively

Common Among Drug-Dependent Offenders—Its Apparent Sources

Related to Emotional Stress, Peer Influence, and Interpersonal Relations.

Thus, sound public policy would provide drug-abusing offenders with the

analytical tools and behavior techniques required to identify the situations

with potential for relapse and to avoid and/or cope with them.

Offender Management and Intervention Program Descriptions and

Evaluations Should Consider the Inclusion of Systematic Anecdotal

Research and Ethnographic Research To Foster the Ability To Speak

Qualitatively With More Precision. Successful drug treatment involves a

highly personal and individual conversion process and does not yield easily

to the instruments of science. This is probably due as much to the nature of

conversion as to the limits of science as a means to human understanding.

Honest, experienced, human insight should not be an embarrassment nor

be designed out of formal approaches to understanding.

Technical Assistance and Training

“You don’t lead by pointing and telling people some place to go. You lead by

going to that place and making a case.” —Ken Kesey

A first responsibility of government is coherence. Given the scale of drugrelated research and evaluation activity under way, an annual update of the

research base on which programs can be built with some confidence is in

order. NIDA would be an appropriate lead agency for such an effort—

establishing the report headings in consultation with ONDCP, convening an

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annual scholar/practitioner conference to review the state of the art in each

established area, and publishing a concise annual update for dissemination to

all Federal agencies and their block grantees.

Second, assuming that a periodic update of knowledge is possible and that it

will serve as general guidance for all public efforts, an additional responsibility

of government is to provide an example. Programs with genuine transfer

potential, such as the treatment effort being initiated by the Federal Bureau

of Prisons (Murray, this volume; Pelissier and McCarthy, this volume), should

be made accessible to State and local agencies through documented program

models. Such transfer programs should address the program elements,

operational performance standards for those elements, outcome measures

utilized, structured site visits, Federal and State personnel exchanges and

fellowships, and periodic training sessions and conferences conducted with

related Federal grant-in-aid agencies. This will involve the establishment of an

adequate transfer staff, separate from the line staff who conduct the program.

Third, government should gather and disseminate information on validated

State and local programs. Federal agencies with grant-in-aid responsibilities

are in a unique position of oversight regarding examples of State and local

excellence. This effort will take the form of documented program models,

resource catalogs identifying State and local experts, host site designation

and support, and program development assistance and training. This will

involve a considerable increase in site monitoring to assess the state of the

art rather than only compliance with regulation.

Management Information Systems

“By nature’s kindly disposition, those things beyond a man’s power to

understand do not occur to him at all.” —G. Santayana

Information technology is converging, with a well-known computer and clones

emerging as the hardware of choice and two software groups and/or emerging

as the operating systems of choice (Blumstein 1990). The opportunity to

gather, utilize, and share information will grow exponentially if a few simple

steps are taken. First, begin with the realization that the benefits of progress

in information and management technology have not been universally shared.

Small- to medium-size agencies, which make up the vast majority of criminal

justice and offender management agencies, often lack the resources to identify

and employ available technology. Second, realize that the Federal Government

has a threefold objective requiring the participation of these agencies: the

application of technology to national criminal justice problems, the provision of

assistance to State and local operating agencies, and the generation of credible

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national information. This mix of technology, practicality, and priority provides

a basis for action.

The approach taken by the Bureau of Justice Assistance (BJA) appears

sound. Realizing that BJA funding was small in comparison with State and

local criminal justice expenditures and that agencies without automation were

going to have difficulty gaining funds to purchase and use automation, BJA

has adopted an approach that will make automation more accessible-the

development of basic, public-domain microsystems. Lacking funds to buy

expensive systems, BJA, along with the operating agencies, has created

prosecution, jail, and police systems they could afford.

A similar effort is under way for offender case management. A BJA grantee

is working in concert with the National Consortium of TASC Programs to

develop a public-domain, micro, TASC/Case Management Information System.

This basic generic system is intentionally focused on small- to medium-size

agencies. It is an introductory system, designed to meet the basic management

needs of offender management, to be sufficiently adaptable to allow for local

differences, to be inexpensive to purchase and maintain, and to be easy to use.

There is a doubly heuristic value to the dissemination of basic, generic

systems. As local agencies employ such systems, they not only learn

about the application of technology but also become better able to assess

their management practices and their needs as well as to communicate

them internally and to local decisionmakers. Their consideration for public

treatment agencies is also recommended.

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Treatment: Literature Review. Prepared under grant 87-DD-CX-K050.

Washington, DC: Bureau of Justice Assistance, U.S. Department of Justice,

in press.

230
Office of Justice Programs, National Institute of Corrections, Bureau of Prisons.

A Survey of Intermediate Sanctions. Washington, DC: U.S. Department of

Justice, May 1990.

Rifkin, J., and Howard, T. Entropy. New York: Bantam, 1981.

Toborg, M.; Bellassai, J.P.; and Yezer, A.M.J. “The Washington, DC Urine

Testing Program for Arrestees and Defendants Awaiting Trial: A Summary

of Interim Findings.” Paper presented at the National Institute of Justice

Conference on Drugs and Crime: Detecting Use and Reducing Risk,

Washington, DC, June 1986.

Weinman, B.A. “Managing the Drug Offender.” Paper presented at the annual

meeting of the Academy of Criminal Justice Sciences, Denver, CO, March

1990.

AUTHOR

John Gregrich

Chief

Corrections Branch

Bureau of Justice Assistance

633 Indiana Avenue, N.W.

Washington, DC 20531

231

316-269 0 - 92 - 9 QL3
A Coordinated Approach for DrugAbusing Offenders: TASC and Parole

Beth Weinman

INTRODUCTION

Moving the offender from the institution to the community always poses

certain risks; with regard to the drug-involved offender, these risks are even

more acute. Reintegrating the drug-involved offender into the community from

the institution should follow a specific course that monitors the occurrence of

drug use and drug-using behaviors. This monitoring should include specific

and suitable referrals to treatment and a treatment plan based on a thorough

assessment of the offender; a substantial course of supervision contacts that

create accountability measurements and include drug testing and the use of

graduated sanctions for misbehavior; and unbroken contact and communication

between community corrections, specifically parole, and treatment.

In many jurisdictions, parole and TASC (Treatment Alternatives to Street

Crime) work in partnership to effect successful intervention with the druginvolved parolee. Through this systems approach, public safety is protected

and the individual offender receives the appropriate clinical support to effect

and sustain new behaviors.

This chapter examines TASC and parole from a historical perspective and

discusses the benefits in managing the drug-involved offender through the

development of a solid partnership between TASC and parole.

THE CHANGING CHARACTER OF TASC

The roots of TASC can be found in the major Supreme Court ruling Robinson

v, California, 370 U.S. 660 (1962), which established that addiction was not

in and of itself a crime and that a State could use its coercive power to

compel addicts into drug treatment. Following Robinson, the Treatment and

Rehabilitation Act was passed in 1966, establishing statutory authority for

involuntary commitment to both residential and outpatient treatment as an

alternative to prosecution. This act was strengthened further in 1970 with the

232
passage of the Comprehensive Drug Abuse Prevention and Control Act,

which authorized, under specific circumstances, that a defendant could be

diverted into treatment for nonviolent charges if he or she was found to have

a dependence on opiates.

In 1972, the Special Action Office for Drug Abuse Prevention (SAODAP) was

created. Discussions among SAODAP, the Law Enforcement Assistance

Administration (LEAA), and the National Institute of Mental Health’s Division

of Narcotic Addiction and Drug Abuse pursued the development of specific

program models to provide both diversion and alternative sentencing designs

that would effectively break through the cycle of drug use and criminal behavior.

Out of these discussions, the original TASC model was created (Bureau of

Justice Assistance 1988a).

Originally, TASC programs operated as diversion programs for nonviolent

opiate users. The key elements of TASC were to (1) identify the opiate-using

defendant through drug testing and jail interviews, (2) refer and escort the

identified defendant to the most appropriate treatment modality, and (3) monitor

the defendant through his or her course of treatment by communicating with

and reporting to both the treatment professional and the criminal justice referral

source throughout the defendant’s time in treatment.

Early local evaluations of this approach found that TASC programs effectively

garnered the support of the criminal justice and treatment systems, intervened

with defendants to reduce drug use and criminal activity, linked the criminal

justice system with the treatment system, identified previously untreated drug

offenders (55 percent), improved defendants’ treatment performance, and

seemed to reduce rearrest rates-only 8 percent of defendants in all 22 local

sites were rearrested for a new offense while in TASC (System Sciences, Inc.

1978; Lazar Institute 1976).

The National Institute on Drug Abuse Treatment Outcome Prospective Study

(TOPS) (Hubbard et al. 1989) examined the impact of TASC and TASC-like

programs. These 1983 and 1985 studies compared criminal justice-involved

clients (in TASC and under other justice system supervision) with a voluntary

control group (no legal supervision) and found that TASC clients under legal

coercion remained in both residential and outpatient treatment modalities 6 to 7

weeks longer than other criminal justice-referred or voluntary clients-a finding

usually associated with better treatment outcomes. TOPS also found that the

case management function of TASC seemed to encourage this longer

treatment participation.

233
Federal funding for TASC ended with the demise of LEAA, but TASC

programing at the State and local levels continued. TASC programs were

expanded and enhanced to provide offender management services for the

presentence, postsentence, and postrelease drug offender population. TASC

program models also were developed to provide TASC offender management

services to juveniles, polydrug users, alcohol abusers, and an array of other

special populations, such as the dually diagnosed. As of August 1991 there

were 178 TASC programs in 32 States (Bureau of Justice Assistance 1989).

In 1984, the Justice Assistance Act again provided States the option of Federal

funding for TASC program implementation, expansion, or enhancement.

Through Justice Assistance Act discretionary funding, TASC program

development, technical assistance, and training became available to States

and local jurisdictions. This discretionary effort also led to the development

of a specific TASC program discipline, creating a basic and proven effective

infrastructure for TASC program development, implementation, and evaluation.

This TASC discipline established the fundamental elements critical to

successful TASC programing (figure 1). Within each element, performance

indicators are documented, creating a basis upon which TASC funders and

program managers are able to measure the strengths and weaknesses of the

local TASC program effort, based on each individual element. These elements

are further broken down into organizational elements and operational elements

and provide a solid design for the management of the drug-involved offender

population (Bureau of Justice Assistance 1988a).

Both legislative acts that followed the Justice Assistance Act-the Anti-Drug

Abuse Act of 1986 and the Anti-Drug Abuse Act of 1988—also included TASC

programing as a model for managing the dependent offender. Although TASC

is not cited specifically in these acts, many of the principles that define TASC

are cited, such as identifying and meeting the alcohol and other drug treatment

needs of the drug-dependent offender (Omnibus Anti-Substance Abuse Act of

1988, State and Local Narcotics Control and Justice Assistance Improvements,

Section 1821, 1988).

More recently, a national TASC survey (Tyon 1988) found that more than 80

percent of the TASC programs that follow the critical elements worked with

probation and parole populations in addition to pretrial populations. These data

may suggest that, during the withdrawal of Federal funding, TASC programs

moved to provide necessary services for community and community corrections

to sustain local funding and to survive.

Perhaps one of the most significant findings from the Tyon (1988) study is the

extent of TASC clients’ treatment experiences. For example, in 1986 about

234
FIGURE 1. TASC system flow by element

SOURCE: Bureau of Justice Assistance 1988a

two-thirds of TASC clients nationwide had never been in any type of alcohol or

other drug treatment program before their involvement with TASC. These data

suggest that TASC successfully continues to identify and refer to treatment

drug-involved offenders who have never received treatment.

235
THE CHANGING CHARACTER OF PAROLE

The word “parole,” from the French word meaning “word of honor” and first used

in 1846 by Boston penal reformer Samuel G. Howe (Giardini 1959), currently

involves two distinct operations: (1) “parole release,” the procedures used to

establish the periods of confinement that prisoners serve; and (2) “parole

supervision,” the conditions and provisions that regulate parolees’ postprison

lives until final discharge from their sentence.

For almost a century, parole has been an established part of American

correctional theory and practice. It has the ostensible purposes of ensuring

that imprisonment is tailored to the needs of the individual inmate, ameliorating

the harshness of long prison sentences and hastening the offender’s

reintegration into the community when it appears that he or she is able to

function as a law-abiding member of society. In addition, parole has the more

subtle intent of alleviating the crowding in correctional institutions and assisting

in the social control of prison institutions through the threat of parole denial for

instances of misbehavior.

The parole process is grounded in the principles of indeterminate sentencing

and “good time” laws. Indeterminate sentencing calls for a period of

incarceration with a fixed minimum and a fixed maximum. Sentences of

1 to 5 years, 10 to 20 years, and 15 years to life are indeterminate, with the

actual amount of time served determined by the paroling authority. The

philosophy behind the indeterminate sentence is based on a purely correctional

model of punishment, the underlying premise being that the sentence should

meet the needs of the offender. After incarceration, at least in theory, the

rehabilitation process is initiated, and the inmate should be confined until

there is evidence of “correction.” At that point, it becomes the responsibility

of the paroling authority to assess the nature and extent of such correction

and release the inmate if the evidence so warrants. As such, indeterminate

sentencing rests on the notion that the length of imprisonment should be

based on progress toward rehabilitation (Carr 1969).

Good time laws evolved to serve a variety of purposes: to assist with the

correction of prisoners, to mitigate the severity of penal codes, and to

encourage good work and good behavior from inmates (Wines 1868). Such

laws specify the amounts of time to be deducted from the period to be served

in prison on a given sentence (and/or under correctional agency control). In

some jurisdictions good time credits are contingent on good behavior, whereas

in others they are awarded automatically. In either case, good time can effect

both parole release and parole discharge.

236
The treatment approach to the management and control of criminal offenders

in this country was initiated early in U.S. history, and by the middle of the 20th

century the idea of “changing the lawbreaker” had become a dominant force in

correctional thinking. Most offenders still were “punished,” but at the same time

institutional classification efforts were designed to direct inmates to programs

that were designed for community reintegration.

During the mid-1970s criminal justice processing in general, and corrections

and parole in particular, began to experience serious challenges on several

fronts.

First, the volume of serious crime in the United States had more than tripled

from 1960 through 1975. In particular, the rate of crimes against property had

increased by 178 percent, and the rate of violent crime had expanded by almost

200 percent (Federal Bureau of Investigation 1976). At the same time, there

was growing opposition to the Supreme Court decisions that many politicians

and social commentators claimed were “handcuffing” the police and “coddling

criminals” (Harris 1969, 1970; Cronin et al. 1981; Curtis 1985).

Second, public concern over the growing crime rate and fear of crime led

to more focused attention on the effectiveness of correctional treatment.

Throughout the 1950s and most of the 1960s much literature had accumulated

that offered testimony to the successes and failures of a variety of therapeutic

approaches. The leading notion and projection of this literature was a rather

gloomy outlook for the rehabilitative ideal (Bailey 1966; Hood 1967). For

the most part, these findings were ignored until the appearance of Robert

Martinson’s well-known “What Works?” article (Martinson 1974). Based on

a study by the New York State Governor’s Special Committee on Criminal

Offenders (Lipton et al. 1975), Martinson’s article implied that, with few

isolated exceptions, nothing worked! Although Martinson had overstated his

conclusions, this report created a media sensation, and there was a marked

loss of faith in the rehabilitative ideal.

Third, growing public concern over the crime problem, spreading acceptance

of a “nothing works” philosophy, and greater politicization of criminal justice

policy all combined to spark a movement toward determinate sentencing

reform. Determinate sentencing, stipulating incarceration for a fixed time

period, empowered prosecutors while placing limits on the discretion of judges

and parole boards. At the same time, beginning in 1976 there was a movement

to abolish parole, resulting in the elimination of parole boards or severe

curtailment of their discretionary authority to release in many States and in the

Federal jurisdiction (Smith et al. 1989). An overall consequence of these

factors was explosive growth in the penitentiary population (table 1).

237
TABLE 1. State and Federal prisoners, 1950-88

Year Total Percent Change

1950 166,123 -

1955 185,780 11.8

1960 212,953 14.6

1965 210,895 -1.0

1970 196,429 -6.9

1975 240,593 22.5

1980 329,821 37.1

1985 502,207 52.4

1988 627,402 24.8

SOURCES: Bureau of Justice Statistics 1982, 1989

Fourth, although the trend toward determinate sentencing may have limited

the discretion of parole authorities, the number of inmates who were released

under the jurisdiction of parole agencies increased significantly. Along with

determinate sentencing came a rise in the number of “mandatory release”

cases-inmates eligible for early release as the result of accumulated good time

credits. Mandatory release inmates are not subject to discretionary parole

release; however, they are subject to a period of community supervision equal

to the amount of good time deducted from their maximum sentence. Also

during this time, the inmates who were released were becoming more volatile,

mentally impaired, and drug dependent (Friel 1989). The responsibility for this

supervision belonged to the parole agencies that were being asked to do more

with fewer resources.

Fifth, and finally, there is an association between drug use and street crime,

which has intensified with the “crack” cocaine epidemic and the contemporary

‘war on drugs.” For more than two decades, research has focused on the

relationship between drug use and criminal activity (Johnson et al. 1985;

lnciardi 1981, 1986; Nurco et al. 1990). The overwhelming evidence suggests

that, although drug use does not necessarily initiate the lawbreaking careers of

the majority of drug-involved offenders, it certainly intensifies and perpetuates

criminal lifestyles. In addition, the National Institute of Justice’s Drug Use

Forecasting (DUF) program offers dramatic documentation of the prevalence of

drug use among arrestees. DUF routinely conducts drug testing on a sample of

arrestees in major cities across the Nation (Wish 1987a, 1987b). The presence

of drug use among arrestees in all the cities surveyed was considerable, clearly

documenting the widespread drug abuse among arrestees.

238
TASC/PAROLE PARTNERSHIP

The partnership between TASC and community corrections continues to

strengthen. These two seemingly separate approaches share a common

infrastructure that complement and improve each other. TASC and community

corrections share the common goal of offender management; TASC’s specific

goal is drug offender management. TASC and community corrections also

share the common dilemma of being perceived as simply an enhancement of

the criminal justice system, rather than the basic infrastructure on which the

continuity of offender management can be achieved.

Together, TASC and community corrections can move the offender through the

components that define the criminal justice system. These components include

(1) alleviating such pressures as court and prison crowding; (2) ensuring drug

offender identification, assessment, and monitoring that includes swift and

certain sanctions; and (3) maintaining unbroken communication with other

participants in the criminal justice system.

BENEFITS OF A TASC/PAROLE PARTNERSHIP

Given the increasing proportion of drug-involved offenders entering the justice

system, the pressures on crowded correctional institutions, and the changing

character of prison release procedures, the benefits of TASC programing to

parole and other community corrections agencies are numerous. As both

TASC and community corrections have diversified to service the changing

political, community, and offender needs, each has developed more expertise

in working with and managing offender populations.

When reentering the community, most parolees are confronted with many

obstacles. Environmental, familial, social, and peer group pressures may

contribute to violations of parole conditions and/or committing crimes.

These pressures tend to be especially acute for those with histories of drug

involvement. Intervention into the drug-abusing lifestyle is perhaps the most

difficult challenge faced by parole officers/agents and treatment practitioners,

Moreover, there are systemic communication problems, such as lapses

between treatment providers and parole authorities, that exacerbate these

difficulties.

Given this pivotal period for parolees with histories of drug involvement, it is

critical to develop effective aftercare support systems to foster alternative

lifestyles and behaviors. Yet in the majority of jurisdictions, prison crowding,

excessively large parole caseloads, and poor communication within the justice

system have hindered the efficacy of both preparole and aftercare supervision

239
services. The establishment of coordinated programing by parole and TASC

assists in reducing barriers that hinder success.

The ideal parole/TASC partnership includes agreements among all the primary

policymakers within the department of correction, parole authority, and the

single State agency that oversees drug abuse treatment services. Although a

partnership might be fraught with overlap and problems of dual supervision,

TASC programs in association with parole are structured to intensify and

complement parole supervision in such ways as those identified below.

Preparole Screening

TASC works with the institutional correctional system as a drug offender

specialist to identify and thoroughly assess drug-involved offenders.

Preparole screening conducted by TASC can provide more comprehensive

background data on drug abuse and related behaviors, including high-risk

behavior for acquired immunodeficiency syndrome (AIDS), to make an

informed release decision. For the paroling authority and its community

supervision staff, this information represents a more thorough appraisal of

the severity of the individual offender’s drug problem and his or her potential

risk to the community. This thorough assessment also allows for more

accurate offender/treatment matching, which has been found to provide a

better likelihood for retention in treatment (Gottheil et al. 1981).

Service Delivery

TASC offers advantages for both corrections and parole. TASC case managers

specialize in developing and implementing aftercare plans for drug-involved

offenders. In addition to drug abuse treatment, TASC provides drug testing,

employment advocacy, client referral to other segments of the local human

service delivery network, and followup reporting to community corrections.

As such, treatment and support services can be offered within a “clinical” rather

than a “correctional” setting. The parole authority benefits because primary

responsibility of supervision is neither limited nor compromised by the parolee’s

treatment needs. Rather, with TASC and parole working in partnership,

communication is increased with TASC as the conduit between the corrections

system and the treatment system. This openness helps in ensuring that the

offender’s needs are met, while at the same time promoting community safety.

This open communication is not to be taken lightly. Historically, the

communication between treatment and parole has been fraught with

miscommunication due to each system’s terminology (table 2). TASC

expertise is maintained as drug offender case management by effecting

240
TABLE 2. Alternative systems terminology

Corrections Neutral/TASC

Term Term

Treatment

Term

Offender Subject

Prison Facility

Surveillance Management

Sentence Time

Criminal behavior Presenting problem

Completion of sentence Goal

SOURCE: Bureau of Justice Assistance 1988b

Client/patient

Residence

Counseling

Treatment

phase

Disease

Recovery

clear communication between the paroling authority and the drug treatment

provider.

Clinical Efficacy and Compulsory or Coercive Treatment

The partnership between community corrections and TASC continues to be

highlighted in this area. Compulsory treatment for drug abuse has been legally

possible for almost three decades, and for almost as long, researchers have

examined its effectiveness. Clinical experiences with the California Civil Addict

Program, the Federal Narcotic Addict Rehabilitation Act program, and coercion

into therapeutic communities have demonstrated more positive results with

compulsory than with voluntary treatment (Anglin 1988; De Leon 1988;

Leukefeld and Tims 1988).

In this regard, research suggests that TASC represents an effective

complement to parole by enhancing the key variable most related to successful

outcome in drug treatment-length of stay in treatment; drug abusers who are

coerced into treatment tend to remain longer than those admitted voluntarily.

The TASC model, as a very specific model of coercive treatment, has proven

effective in retaining clients in treatment because TASC clients remain in

treatment longer than other criminal justice clients and non-criminal justice

system referrals (Hubbard et al. 1989).

Alleviation of Prison Crowding

TASC can assist in two ways. First, by relying on a TASC treatment

recommendation, scarce treatment slots will be allocated to drug users most

241
in need of and responsive to treatment. Again, thorough, accurate

assessments increase the chances of treatment success while reducing

the chances of relapse and future criminal behavior, arrest, and incarceration.

Second, TASC aids the parolee in successfully completing his or her term

of supervision. Periodic drug testing, site visits, and case conferences tend

to become a useful deterrent and foster program compliance (lnciardi 1990).

THE TASC/PAROLE PARTNERSHIP OF THE 1990s

Legislators and other policymakers are requesting quantitative data to

support program effectiveness. As specific program data become the focus

of attention, it is critical that accumulated knowledge and accomplishments

not be overlooked; they should be considered future building blocks.

Professionals know “what works” but are not consistent in documenting what

works or specifically how programs work. Effective program approaches must

be defined, documented, and disciplined to allow specific research approaches

to be put in place for program evaluation. Using the coordinated partnership

between TASC and parole as an example, clarity can be achieved by defining

the four principles that support this system of drug offender management:

(1) early identification of the drug-involved parolee to allow for intervention in

to his or her drug-using behavior before release; (2) thorough assessment to

match the appropriate treatment with an adequate number of supervision

contacts; (3) substantial monitoring to get the offender’s attention and, when

strengthened by swift and certain sanctions for misbehavior, to retain the

offender’s attention so that treatment has a chance; and (4) unbroken contact—

from prerelease through end of parole-to remove the problems of time delays

and breaches in communication that often imply detachment between parole

and treatment (Gregrich and Weinman 1990).

These four basic principles define the TASC/parole partnership. However,

they must be further defined, documented, evaluated, and promulgated. The

systems approach to effecting a successful term of drug offender community

reintegration and treatment can be effective in changing behaviors as

previously noted. Policymakers can begin to seek funding services as well

as evaluations to further strengthen systemwide approaches and to allow for

documentation that will ease replication and implementation efforts at the State

and local levels. Rather than continuing to seek “new,” "snappy,” and unproven

program titles, it is time to begin to support those program models that have

proven effective at the local level. Finally, we should profit from what we have

learned over the past 20 years: that treatment and corrections along with TASC

can work together effectively-without interruption and without turf agendas.

242
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244
AUTHOR

Beth Weinman, M.A.

Transitional Service Coordinator

Drug Program

Federal Bureau of Prisons

NALC Building, Room 301

320 First Street, N.W.

Washington, DC 20534

245
Methodological Issues: Drug Abuse

Treatment Research in Prisons and

Jails

Bennett W. Fletcher and Frank M. Tims

INTRODUCTION

Although many of the methodological issues encountered in drug abuse

treatment research for the incarcerated population overlap with those in the

nonincarcerated population, the incarcerated population is also unique in many

respects. Some of these differences create research opportunities, whereas

others complicate the design and implementation of research and may threaten

to compromise the investigation or the interpretation of results.

The intention of this chapter is to alert the reader to several methodological

pitfalls encountered in designing and conducting treatment evaluation research

with incarcerated populations. A thorough review of every methodological

issue involved with the evaluation of treatment in the incarcerated population

is beyond the scope of this chapter. Issues concerned with statistical and

analytic approaches or detailed discussions of what variables and phenomena

to measure are not covered here. For a discussion of issues surrounding

treatment evaluation, the reader is referred to Sells and colleagues (1977)

and Tims (1982). Wells and coworkers (1988a, 1988b) provide an overview

of measurement issues. Hubbard and colleagues (1989) review the treatment

effectiveness literature and describe findings from a large-scale treatment

outcome study.

Research Questions

Evaluation research questions that might be asked of an incarcerated

population receiving drug abuse treatment include the following: Does

treatment produce behavior change, and if so, how? What treatment

approaches and components are optimal, and for whom? How can

treatment be improved? How does the prison context influence treatment

process and outcome, and how can contextual constraints be overcome?

246
Do prison-based treatment effects persist beyond the period of incarceration?

How well does prison-based treatment prepare individuals for reentry into the

community? These questions concern process and outcome, environmental

or situational influences in prison-based treatment, and the period of transition

from prison-based treatment to community treatment. Needless to say, to

answer such questions requires that treatment effects be distinguished from

unrelated factors that also may influence treatment outcomes or its process.

Research Design

There is a substantial literature on research design, including experimental

(Fisher 1960; Kirk 1982; Winer 1971) quasi-experimental (Campbell and

Stanley 1963; Cook and Campbell 1979; Trochim 1984), and nonexperimental

research (Duncan 1975; James et al. 1982). Within the context of experimental

and quasi-experimental designs, Campbell and Stanley (1963) describe threats

to internal validity (whether the results of the research findings are true) and

threats to external validity (whether the research findings are representative

or generalizable outside the research context). Nine types of threats to internal

validity are history, maturation, instability, testing, instrumentation, regression

artifacts, selection biases, attrition, and selection-maturation interactions

(Campbell 1969). The threats to external validity, which apply equally to

experimental and quasi-experimental research, include the interaction

effects of testing, the interaction of selection and experimental treatment,

the reactive effects of the research, multiple-intervention interference,

irrelevant responsiveness of measures, and irrelevant replicability of

treatments.

The process of randomization, when properly carried out, controls for most

threats to internal validity (Campbell and Stanley 1963). For this reason,

experimental research designs that incorporate random assignment of

subjects to treatment groups often are regarded as the sine qua non of

treatment research and are recommended if feasible (Coyle et al. 1989; GrayDonald and Kramer 1988). Treatment outcome or evaluation research that

does not use a randomized design may be subject to criticism. This criterion is

focused largely on the risk that the treatment effects have been confounded

with extraneous sources of variation, particularly self-selection bias, which

may jeopardize the interpretation of treatment results. However, in treatment

evaluation research, characteristics of the population, the environment, and the

treatment each may threaten the validity of the randomization process, with the

consequence that a randomized design is often not feasible or is compromised

during implementation. Many of the pitfalls described in the following sections

are particularly problematic within the context of a randomized design because

they reintroduce threats to internal validity.

247

318-269 0 - 92 - 10 QL3
THREATS TO INTERNAL VALIDITY

History

Events that occur concurrently with the treatment or in the time between

the treatment and posttreatment measurement may influence the outcome

behavior. For example, a change may occur in the level of supervision of a

prison inmate, which may change the level of drug use or the motivation to

change, independent of treatment participation. Randomization controls for

preassignment historical influences but does not control for events that occur

during or after treatment (Campbell and Stanley 1963). The potential for

extraneous events to influence outcome behaviors is greater with a longer

duration of treatment. Given this fact and given that interest in outcomes may

extend indefinitely beyond treatment, intervening events should be monitored

for the duration of treatment and followup periods. This monitoring will help

determine whether significant events have occurred to systematically influence

the criterion behaviors, which could result in misattribution of treatment effects.

Maturation

Maturation becomes a threat to the validity of treatment effectiveness

attributions when the natural process of change over time influences

outcome behaviors. For example, research in the drug-using behavior of

juvenile delinquents should take into account developmental changes that

predispose that population to use or stop using particular drugs. However,

given the long-term nature of drug addiction and treatment, maturation also

may be a competing explanation for changes in adult drug use (Winick 1962.

1964; Brecht and Anglin 1990).

Testing and Instrumentation

An individual who is to be followed over time typically enters a research

study naive to its procedures and goals. As the project continues, a subject

learns or infers procedures or goals and may shape his or her responses

accordingly. This could have a positive effect if the investigator is able to elicit

more accurate and detailed data. However, the subject’s perception of the

research or the investigator also may produce biased, unreliable, or erroneous

data. Particularly with self-reports, data quality depends largely on the

participant’s belief in the importance of the research and the integrity of the

investigator (Homans 1977) as well as his or her confidence that the researcher

will prevent the misuse of sensitive or incriminating data (Robins and Smith

1977). Inmates tend to be cynical, manipulative, and resistant to authority

(Wexler and Williams 1986). In conducting research in the criminal justice

248
population, it is of critical importance to establish the interviewer’s integrity and

credibility.

Statistical Regression

Statistical regression occurs when individuals who exhibit extreme behavior

are selected for entry into a study. Extreme behaviors tend to moderate over

time, making it difficult to separate treatment effects from a return to more

normal behavior. This is a well-recognized problem that is endemic in drug

abuse treatment research because individuals typically enter drug treatment

as the result of a drug or legal crisis (Simpson and Sells 1982; Wells et al.

1988b). Incarcerated individuals may have fewer options on when and whether

to enter prison-based treatment and, thus, may not represent extreme drugusing behavior prior to treatment. On the other hand, it is not uncommon for

the prison administration to select its most troublesome inmates for treatment.

Selection and Selection-Maturation Interaction

Threats to validity from selection represent another well-known problem for

drug abuse treatment research. Selection biases may occur for several

reasons. The assigned treatment may be unavailable; the individual may

refuse or be unable to accept the assigned modality; or clinical judgment may

override the assignment (Bale et al. 1980; McLellan et al. 1983). Selectionmaturation interactions are a threat when subjects predisposed to change

selectively enter or stay in a particular type of treatment, thus making the selfselected treatment appear more effective than a comparison treatment. GrayDonald and Kramer (1988), in discussing a disparity between observational

and clinical trial outcomes, suggest that psychologic factors, indication for

treatment, and uncertainty regarding precedence of treatment and outcome

are important potential confounds in observational studies, which include

prison and jail studies.

Attrition

Attrition reintroduces the threat of self-selection bias. Attrition resulting from

random, unrelated factors may not jeopardize internal validity (although

statistical power is reduced); however, if the reason for dropping out is related

to the intervention, bias has been introduced to the sample whether random

assignment procedures have or have not been followed. Differential dropout

rates are an indication of bias, but similar dropout rates do not guarantee its

absence. Attrition occurs for several reasons. Subjects have treatment

expectations and may drop out if these expectations are not met, or they may

drop out after learning more about the research protocol or the assigned

treatment.

249
Mosteller and coworkers (1983) note that investigators often underestimate

subject loss due to inclusion or exclusion criteria, clinical acceptability of the

assigned treatment, and subject refusals, resulting in overoptimism about

the number of subjects that can be recruited into a clinical study. In an

analysis of randomized field experiment implementation in criminal or civil

justice evaluation studies, Dennis (1988) found that 13 of 28 studies had

overestimated their case flows. Howard and colleagues (1986, 1990) argue

that attrition should include not only dropouts but also those who constitute

“effective dropouts,” since they remain in the study but fail to provide complete

data.

Although the restricted range of desirable alternatives to prison-based treatment

may reduce dropout rates, it is unlikely that attrition will be eliminated entirely.

An assessment of the reasons for discontinued participation may permit the

degree of sample bias to be estimated. Such an assessment should be easier

in a sample of subjects incarcerated or under legal supervision rather than in a

community sample: nevertheless, subject loss to followup should be anticipated.

THREATS TO EXTERNAL VALIDITY

To study treatment, data must be gathered. However, the data collection

procedures are often sufficiently intrusive to alter treatment, thereby reducing

generalizability beyond the treatment program under study. Threats to

external validity may be the most troublesome for treatment evaluation

research because they are not susceptible to remedy through such

statistical procedures as randomization or covariance analysis.

lnteraction of Pretreatment Data Collection

Pretreatment data are often necessary to establish a baseline from which to

evaluate behavioral changes during and after treatment, to match subjects,

or to control for differences in client characteristics. These data usually are

obtained by interviewing the incoming client. However, obtaining pretreatment

baseline research data may increase the subject’s sensitivity or treatment

responsiveness, resulting in outcomes that differ from the treatment delivered

without pretreatment data collection.

A solution to this problem is to reduce the intrusive nature of data collection as

much as possible. This can be accomplished by using existing data sources,

by incorporating data collection into the ongoing treatment process (this

changes the nature of treatment and may affect reliability and validity of data),

or by using unobtrusive outcome measures.

250
Interaction of Selection Biases and Treatment

There is evidence that differences exist in the drug patterns, legal

involvement, and sociodemographic characteristics of clients or patients

entering different treatment modalities (Sells 1974; Hubbard et al. 1989).

There is also evidence that individuals with particular characteristics

(e.g., level and type of psychopathology, pattern of drug use, or criminal

involvement) perform more appropriately in some modalities and more

poorly in others (McLellan et al. 1984, 1986). Over time, treatment preference

and reason to enter treatment are predictive of treatment outcomes (Lehman

et al. 1990). These differences suggest that, in general, treatment findings

must be interpreted in the context of client characteristics and preferences.

Reactive Effects of Research Arrangements and Irrelevant

Responsiveness of Measures

Introducing research arrangements to measure treatment performance may

influence behaviors under observation and confound measuring treatment

effects. Even in well-designed studies, obtaining research data is an intrusion

and introduces changes in the treatment process that may influence outcomes

in unpredictable ways. For example, conducting during-treatment interviews,

recording treatment sessions, or taking frequent biological specimens may

increase compliance with treatment requirements, thus making the treatment

appear more effective. In addition, data collection instruments may contain

components that appear to be related to outcome but measure factors

specifically related to the particular program being studied (e.g., a singularly

effective counselor or program administrator), which compromises the

generalization of treatment evaluation results to other settings.

Multiple-Treatment Interference

Depending on the treatment modality, between 34 and 75 percent of the clients

in the Treatment Outcome Prospective Study had prior treatment experience,

and from 14 to 44 percent had been in treatment three or more times (Hubbard

et al. 1989). Marsh and coworkers (1990) discuss the difficulties of evaluating

the effects of specific treatment episodes in the context of multiple treatment

admissions over time. These effects may have cumulative, sequential, or

delayed influences on outcome. The prison experience may be conceived as a

complex and multifaceted intervention that interacts with treatment in ways not

well understood.

251
Irrelevant Treatment Replicability

The treatment process is complex and difficult to measure. Research findings

attributed to measured variables may not be replicated if outcomes are the

result of other unmeasured (or poorly measured) factors. For example, there

is evidence that program and environmental factors (Finney and Moos 1986;

Finney et al. 1981; Moos 1970), the organizational environment (D’Aunno and

Price 1985), and counselor characteristics (McLellan et al. 1988) significantly

influence treatment outcomes. Even within the same program, interventions

vary from one individual to another depending on the needs and attributes of

the patient, with the consequence that it is difficult to determine what is being

evaluated.

THREATS TO IMPLEMENTATION AND POSSIBLE REMEDIES

The discussion thus far has described threats to validity that might be

encountered in community-based as well as in criminal justice research.

However, many of the characteristics unique to the criminal justice environment

have a profound impact on the nature of research carried out in it. Treatment

research in prisons and jails is influenced by (1) the institution’s security level;

(2) the inmate composition and culture; (3) the administrative philosophy

and structure; (4) the physical environment; (5) the prison’s regulatory structure,

with swift consequences for rule infractions: and (6) the motivation and attitudes

of prison and program staff.

Prisons are fundamentally unpleasant places designed to confine individuals

convicted of crime and to deprive them of individual liberty. Because of

the atmosphere of mistrust, threat, and suspicion between prison staff and

inmates, together with inmate unrest and overcrowded conditions, the prison

environment is often not conducive to therapeutic intervention or rehabilitation

(Wexler et al. 1988). Wexler and Williams (1986) eloquently identify several

barriers to effective implementation of treatment programs, including

institutional resistance, the severity of inmate problems, and program

inadequacies.

Whether in Federal, State, or local institutions, research on inmates is

conducted at the discretion of criminal justice officials whose primary mission

is to maintain public safety by ensuring that those in custody present minimal

risk to the public. Although community-based treatment program directors are

not likely to be held responsible for the criminal activity of their clients, the

warden of the correctional institution is responsible for individuals under custody

and supervision. Research or clinical interventions that present unattractive

risks to correctional officials (e.g., releasing an inmate who might recidivate to a

252
community halfway house) are not likely to be fully implemented regardless of

progress made in treatment. Therefore, inmate security considerations override

clinical and research considerations.

In a synopsis of the Stay’n Out evaluation, Wexler and colleagues (1990,

p. 71) noted that

while correctional institutions are generally hostile

environments that impede attempts at both treatment and

research, both can be accomplished successfully, even

though it is highly difficult to maintain the integrity of treatment

programs and research studies within correctional facilities.

Researchers are usually not regular members of the institution, since their

roles, activities, and objectives are different and since their research findings

may be perceived to have dubious value to the institutional program being

studied. Thus, a researcher often has a marginal position within the

organization (Rodman and Kolodny 1964). The result of this organizational

isolation is that an investigator often must rely heavily on the cooperation of

many levels of criminal justice administration, from administrators to

treatment staff, most of whom have little experience with, appreciation

for, or understanding of research. Often, an inordinate amount of the

researcher’s time must be focused on establishing and maintaining

cooperative relationships with the administration, prison staff, and subjects

so that research and treatment goals can be accomplished.

Randomized Designs

Since individuals who are incarcerated constitute a “captive” study population,

it could be expected that implementing a randomized design would be easier

in prison-based treatment. However, many of the problems encountered in

community-based treatment research are present in the criminal justice

environment, making implementation of this potential design difficult to realize.

In noting that randomized field experiments are often “logistical failures,” Dennis

(1990) identifies six categories of potential methodological problems that may

jeopardize the implementation of randomized drug treatment studies: dilution

of treatment, contamination or confounding of treatment effects, reduced power

from underestimated caseflow, violations of the random assignment protocol,

changes in the study context or environment, and changes in the treatment

being delivered.

As in settings outside the criminal justice environment, conflicts often arise

between research and clinical goals that must be resolved. Researcher253
practitioner issues include problems in communicating research goals and

procedures to treatment staff, dealing with staff turnover, and convincing

clinical administrators that randomization is necessary and ethical (Ashery and

McAuliffe, in press). Treatment staffs often fear that assignment to a control

group may unfairly affect those patients, especially those with more severe

problems.

Ashery and McAuliffe (in press) reviewed nine randomized clinical trial studies

and identified problems that threaten to jeopardize the implementation of valid

randomization procedures. In addition to difficulties with client recruitment

and attrition, problems included loss of subjects in the followup, failure to

develop and maintain relationships with outside cooperative agencies, conflicts

between treatment and research objectives, forced modifications to the study,

and project management issues. Some solutions that were identified included

changing the ratio of assignment to randomized groups, aggressive recruitment

and followup techniques, the addition of more treatment or data collection

sessions than originally planned, and incorporation of a prerandomization

period to identify early dropouts.

Treatment vs. no-treatment comparisons rnay be needed to address the

question, “Does treatment work?” However, if the research question is one

of relative effectiveness (e.g., “Is treatment A more effective than treatment

B?“), it may not be necessary to establish a no-treatment control group.

Instead, random assignment to alternative treatments may be used. These

are more likely to be successfully implemented if the alternative treatments

are similar enough or of equally unknown effectiveness so that no strong

preferences exist—among clients or treatment staff—for any particular

treatment alternative.

Randomized designs that employ no-treatment control groups are difficult to

implement because of ethical dilemmas from withholding treatment. If the

demand is such that inmates are on treatment waiting lists, it may be argued

that the fairest allocation of resources is to select subjects by chance.

Petersilia (1989) describes a large-scale evaluation of the Bureau of Justice

Assistance’s Intensive Supervision Probation (ISP) program, in which

randomized assignment was presented to practitioners as a way to allocate

scarce resources and as the only credible way to evaluate the ISP program.

Other Designs

If a randomized design is impractical or unfeasible, quasi-experimental designs

(Campbell and Stanley 1963; Cook and Campbell 1979) may be used. Quasiexperimental designs-such as pre-post designs, time series (Box and Jenkins

254
1976) survival analysis (Miller 1981; Fisher and Anglin 1987) and regression.

discontinuity (Trochim 1984)—control for some but not all threats to internal

validity. Regardless of whether a randomized design can be implemented, a

researcher also must try to measure and control threats to external validity,

which are not controlled by randomization.

Statistical analytic methods can be used to correct for bias from nonrandom

sources of error. Random error, which reduces the precision of estimates but

does not introduce bias, may be reduced through the use of multiple data

sources or multiple indicators to obtain more reliable estimates of important

variables. This is accomplished by reducing mistakes in recording and coding

data and by using data collection strategies that maximize data reliability.

Statistical analytic approaches also can be used, including covariance analysis

(Tatsuoka 1971), factor analysis (Gorsuch 1983), modeling of selection bias

(Heckman 1979), and estimate-and-subtract procedures (Reichardt and Gollob

1989). These corrective techniques incorporate the measurement of biasing

factors but do not correct for unobserved influences, If such an approach is

used, it is necessary to identify and measure potential confounding variables

(e.g., motivation, psychological impairment, criminal orientation, history, ability/

impairment/skill level) along with treatment factors and outcome criteria of

interest.

Causal modeling techniques (Duncan 1975; Namboodiri et al. 1975) also can

provide a means for investigating relationships not generally amenable to

experimental designs. This includes testing complex multivariate relationships

between unobserved variables. Causal modeling techniques generally require

the specification of a structural model and a corresponding measurement

model. The structural model describes the theoretical relationships between

variables, and these relationships are tested with empirical data in the

measurement model using a goodness-of-fit approach. Causal models are

subject to stringent assumptions, well described by James and coworkers

(1982), who also identify common violations in causal modeling applications.

CONCLUSION

Compared with other areas of drug abuse treatment research, relatively little

research has been carried out in jails and prisons. The Stay’n Out study in New

York State prisons (Wexler et al. 1988) significantly increases understanding of

the effectiveness of prison-based therapeutic communities and milieu therapy

compared with no drug treatment. As correctional institutions expand their drug

treatment capabilities, new questions arise with regard to the effectiveness of

correctional drug treatment in different contexts. A variety of treatment options

exist in correctional institutions, including prison-based self-help groups,

255
residential and nonresidential drug treatment programs, prison-based

methadone programs, and ‘treatment prisons” dedicated to drug offenders.

Although it is not difficult to identify interesting research questions in the area

of correction-based treatment, two areas offer substantive and methodological

challenges to the investigator. The first area in which systematic investigation is

needed is the influence that environmental and situational factors have on the

implementation of treatment and on treatment outcomes. Moos and colleagues

(Moos 1970; Moos and Finney 1988) have carried out some work in this area,

but much remains to be done. For example, are community-based treatment

outcomes different from prison-based outcomes, and if so, are the differences

related to prison vs. community context or to other factors?

The second area is transition to the community. Recovery from drug abuse is

usually a long-term process. The transition to the community from a highly

structured and controlled environment is a remarkable change, even if the

previously incarcerated individual progresses through several stages such

as a halfway house, community residential treatment, and parole supervision.

Specific questions might focus on such areas as the following: Do the effects of

prison-based treatment persist beyond the period of incarceration? Does drug

treatment in the correctional institution adequately prepare the incarcerated

substance abuser for reentry into the community and for resisting pressure to

relapse or recidivate? How can institutional-based programs more effectively

prepare inmates for reentry to the community?

This chapter draws heavily on drug treatment evaluation research

studies carried out in noncorrectional areas in an attempt to identify possible

problems that may be encountered when implementing treatment research in

the correctional environment. Although this research is challenging and at

times frustrating, the opportunity for groundbreaking research should not be

overlooked. Treatment research in correctional institutions is needed.

Implementation and methodological problems will be encountered, but these

problems are not insurmountable and can provide substantive and

methodological challenges,

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AUTHORS

Bennett W. Fletcher, Ph.D.

Research Psychologist

Treatment Research Branch

Frank M. Tims, Ph.D.

Deputy Branch Chief

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10A-30

5600 Fishers Lane

Rockville, MD 20857

260
Evaluation of the Federal Bureau of

Prisons’ Drug Treatment Programs

Bernadette Pelissier and Dan McCarthy

The Federal Bureau of Prisons’ (BOP) recent renewal of intensive drug

treatment programing is accompanied by a comprehensive evaluation plan.

This evaluation plan is important, given the minimal amount of research that

has been conducted on prison drug treatment programs and the need to

determine “what works for whom” in the drug treatment field.

BOP’s effort will involve process and outcome evaluation as well as cost-benefit

analysis. The purpose of the evaluation is to provide information for supporting

decisions about nationwide efforts to control drug use through drug treatment

programs. It is hoped that the evaluation will guide the development of more

effective drug treatment programs. In addition, it is expected that the evaluation

will provide a greater understanding of the etiology of drug addiction among a

prison population.

This chapter summarizes the research design to be implemented in the

evaluation and highlights those elements that address issues specific to

studying drug treatment programs in prison populations as well as currently

existing knowledge gaps.

EPIDEMIOLOGICAL STUDY

The association between substance abuse and criminal behavior has been

widely debated and researched. Nonetheless, recent research of a longitudinal

nature consistently agrees that addiction acts as a “multiplier” of crime; though

criminality often occurs prior to addiction, the onset of addiction results in

greater levels of criminal involvement (Nurco et al. 1985).

Recent data show that more than 50 percent of all State prison inmates used

drugs regularly before their last arrest but were receiving no programmatic help

while incarcerated (Chaiken 1989). Comprehensive information on drug abuse

problems among Federal prison inmates is currently unavailable. Therefore,

BOP’s research effort will include data collection from a national baseline

261
sample to identify the nature and extent of drug abuse problems among Federal

prison inmates and to obtain information to clarify the association between drug

use and other criminal behavior prior to their current incarceration. This will be

useful in assessing not only the number of individuals in need of treatment and

future program demand but also the severity of their impairment and criminality.

Each year, approximately one-third of BOP’s institutions representing the

various security levels (low, medium, and high) will be selected as part of

BOP’s evaluation effort, so that over a 3-year period all institutions will have

been sampled. One thousand randomly selected inmates newly admitted

to these institutions will be interviewed each year. The interview format—

adapted from previously developed instruments of Nurco, the Bureau of

Justice Statistics’ prison survey, and the Treatment Outcome Prospective

Study (TOPS) (Nurco et al. 1985; lnnes 1988; Hubbard et al. 1989)—addresses

drug use, employment, treatment history, and criminal history as well as family

and other individual background characteristics.

DRUG TREATMENT PROGRAM EVALUATION

The research design involves a regional multisite assessment of residential

treatment programs using four comparison groups, including a random

assignment component. Two 1-year cohorts of these four comparison groups

will be included in this study, which will employ a continuous-time analysis of

event histories. Measures used will be multidimensional, both behavioral and

cognitive, and will incorporate perceptions of program staff and research

subjects as well as observations by research staff. The effect of the programs

on postrelease drug use, criminal behavior, occupational and social functioning,

and mental and physical health will be assessed during a 5-year followup

period.

Subject Selection and Comparison Groups

The evaluation effort will focus on assessing two types of residential drug

treatment programs, 12-month pilot programs and 9-month comprehensive

programs representing high and moderate levels of program intensity. (See

Murray, this volume, for a detailed description of BOP’s drug treatment

programs.) Both programs will be followed by transitional services to assist

inmates in readjusting to community life. Although these programs will be

located in various institutions nationwide, evaluation efforts will be limited

to the Southeastern and mid-Atlantic regions of the country where random

assignment procedures will be incorporated into the program admission

procedures.

282
Inmates eligible for admission to the residential programs, based on evidence

of moderate to severe levels of substance abuse, may volunteer for the pilot

residential programs. The research staff will randomly assign these volunteers

to the high-intensity pilot program or to a comparison group to prevent the

possibility of sabotage of the process by skeptical practitioners. Volunteers

who are randomly assigned to the comparison group will comprise two groups

depending on choices made about other available treatment. One group will

consist of individuals who receive no further in-prison treatment and the other of

individuals who elect to enroll in a comprehensive moderate-intensity residential

program. These various treatment and comparison groups will provide a basis

for comparing the cost-effectiveness of several levels of treatment intensity.

Since program entry requires volunteering, extrapolation of results to the

population of incarcerated drug abusers is not defensible without assumptions

about voluntary self-selection (Singer 1986). The very act of volunteering may

affect outcome. Therefore, a nonvolunteer control group will be selected to

assess both selection bias and the impact of volunteering on outcomes. The

nonvolunteer comparison group will be selected from among those who have

passed the time point appropriate for volunteering (i.e., with less than 12

months of time remaining to serve in prison). Selection of this control group

will be accomplished through a paired or probabilistic matched sample selection

method, which allows for comparisons of similar groups (Rosenbaum and

Rubin 1985; Saylor 1985). Criteria for matching include extent and type of

prior drug use, drug treatment history, criminal involvement, prior incarceration,

educational level, employment status, age, sex, and marital status. It is

estimated that there will be approximately 400 inmates in each of the

comparison groups each year.

If there are too few volunteers to implement random assignment or fill the

available spaces, additional incentives for volunteering may be developed.

However, in the event that inadequate implementation of the random

assignment procedure occurs because of an insufficient number of volunteers,

because of subject refusal to accept program assignment, or because of high

dropout rates or other administrative problems, the ability to account for selfselection biases in drawing conclusions about program effectiveness will be

hindered. Two aspects of the research design are considered crucial to

interpretation of results in the event of incomplete implementation of random

assignment. First, all selected research subjects will be followed regardless of

program participation or when they drop out. Second, the comprehensiveness

of the data to be collected-both behavioral and attitudinal-will allow an

assessment of program participation covariates.

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In addition to the four comparison groups, a regional baseline comparison group

will provide information on volunteerism-information generally unavailable in

most drug treatment outcome studies. The group will be composed of inmates

randomly selected from among all inmates who would be eligible to volunteer

for the pilot treatment programs. Information collected will be similar to that

obtained from the national baseline sample of new admissions. Characteristics

of this group will be compared with those of the pilot program volunteers to

address the following questions: What percentage of incarcerated drug

abusers volunteer for treatment? Are volunteers individuals whose criminal

career is related to drug abuse? Are volunteers individuals with the most

severe drug abuse problems?

Independent Variable Measures

Sociodemographlc Characteristics. The array of background variables to

be collected is similar to that collected in other drug treatment research efforts

(McGlothlin et al. 1977; Collins et al. 1982; Anglin and McGlothlin 1988;

Simpson 1988; Wexler et al. 1985; Nurco et al. 1986: Anglin and Speckart

1988) and can be grouped as follows:

1. Demographic and family characteristics

2. Lifestyle and life changes

3. Alcohol and other drug use

4. Previous treatment experiences

5. Illegal activities/criminal justice system involvement

6. Occupational history

These variables include all behaviors targeted by the programs. Whereas

the priority target behaviors are drug use and criminal activities, others include

social and occupational functioning.

These variables serve two purposes. First, assessment of treatment outcome

requires a comprehensive assessment of pretreatment functioning to provide a

baseline measure for comparison with posttreatment behaviors. Second, these

variables will be used to assess the degree to which these factors account for

variation in treatment retention and outcome success. Although treatment

outcome results pertaining to sociodemographic characteristics are inconclusive

(Anglin and Hser 1990), greater consistency has been shown in research on

predictors of treatment retention (Allison and Hubbard 1985; McLellan 1983).

Crucial to program evaluation is the issue of length and timing of baseline

measures (Wells et al. 1988a; Anglin and Hser 1990). There is some degree

of consensus that baseline periods of 1 or more years are desirable: Shorter

264
periods just prior to treatment entry may bias outcome results toward showing

positive results since they often represent elevated levels of drug use or

criminal involvement (Bale 1979; Sells et al. 1977; Anglin and Hser 1990).

This study, through using a life history calendar technique (Freedman et al.

1988). will have the flexibility of identifying various baseline periods. The life

history calendar obtains detailed information on legal status, illegal activities,

living arrangement, employment, and treatment status for each episode of

addiction or change in drug use behavior after initial drug use.

Cognitive/Psychological Attributes. A major issue emerging in the drug

treatment evaluation field concerns the impact of psychosocial characteristics

and cognitive perceptions on treatment outcomes.

Psychological Impairment. Researchers reviewing and commenting on the

drug abuse evaluation field have noted the need to include more data on the

psychosocial and psychiatric characteristics of drug-dependent clients (Jaffe

1988; Tims and Holland 1988; Hubbard et al. 1988). Individuals who abuse

drugs are an extremely heterogeneous group: and intake symptoms such as

psychological functioning have been found to be a more important predictor

of outcome than pretreatment background characteristics (Cronkite and Moos

1980; Jaffe 1988; Cohen 1986). The heterogeneity of the addict population and

the variation in levels of psychological impairment are important considerations

in addressing the issue of what treatment works with whom.

Level-of-impairment measures will be adopted from those being developed in

the Drug Abuse Treatment Outcome Study project, funded by the National

Institute on Drug Abuse. This coordinated effort also will provide a basis for

comparing incarcerated and nonincarcerated drug-abusing populations.

Motivation. Client motivation and perceptions about treatment have been

identified as important dimensions to include in studies of drug treatment

outcome. Motivation and commitment to change have been reconceptualized

as a dynamic process involving staff as well as environmental and client

characteristics (Miller 1985). Studies of natural recovery from addiction and

long-term followup studies have shown the importance of such characteristics

as client initiative, commitment to renounce drug use, and readiness for

treatment (Waldorf and Biernacki 1981; Havassy and Tschann 1983; Simpson

1988; Hall and Havassy 1986). A study of change processes found variations

in the balance given to pros and cons of drug use across the stages of change

(Prochaska and DiClemente 1986).

The questionnaire to assess motivations and expectations about treatment

includes questions related to reasons for volunteering, positive and negative

265
effects of drug use, expectations about treatment outcome, commitment to

abstinence from drug use, and perceived probability of successful abstinence

after release from prison.

Cognitions About Substance Use. The lack of theory-inferred outcome

variables (proximal outcomes) has been cited as a possible explanation for

the frequency with which program evaluations show little or no effectiveness

(Chen and Rossi 1980). Evaluation of program effectiveness needs to focus

on both proximal and distal (final) outcomes; program failure may result either

from faulty theory or because the proximal outcomes specified by the theory

were not achieved (Rosen and Procter 1978; Jones 1982; Holland 1986).

Relapse prevention theory, the model on which the pilot residential drug

treatment programs are being based, provides a mechanism to assess the

role of theory-inferred proximal outcomes on the distal outcomes of interest.

Relapse prevention is a cognitive-behavioral model with origins in Bandura’s

(1977) self-efficacy theory, which presents a comprehensive and integrated

framework for explaining the change process in psychotherapy. This theory

posits that techniques producing initial behavioral change may be ineffective

at maintaining that change over time and avoiding relapse. Relapse prevention

treatment provides individuals with the behavioral and cognitive skills necessary

to cope effectively with high-risk situations (Marlatt and George 1984; Marlatt

and Gordon 1985).

Two sets of instruments will focus on theoretical assumptions underlying the

pilot treatment programs. These instruments are based on previous research

that has identified seven dimensions of high-risk situations for relapse, including

both intrapersonal and interpersonal situations (Marlatt and Gordon 1985). The

first set of instruments—Inventory of Alcohol Use and Inventory of Drug Use—

identifies situations in which alcohol or other drug use occurred in the past.

The second set of instruments-Situational Confidence Questionnaire and

Drug-Taking Confidence Questionnaire-assesses efficacy expectations, the

individual’s confidence in being able to resist the urge to use drugs in a variety

of situations (Annis 1982a, 1982b; Annis and Martin 1985; Brownell et al. 1986).

The cognitive/psychological data will enable assessment of whether program

volunteers meet the criteria assumed by the relapse prevention theory. In other

words, are program participants deficient in coping skills? Does program

participation affect these skills? Does improvement of these skills decrease

relapse after treatment? Which posttreatment factors are more conducive to

the maintenance of these skills?

266
Treatment Structure and Process. Treatment process is another neglected

area identified by program evaluation theorists as well as researchers

evaluating substance abuse treatment and criminal justice programs (Quay

1977; Reed 1978; Sechrest et al. 1979; De Leon 1988; Hubbard et al. 1988;

Simpson 1988; Tims and Holland 1988). Measures of treatment integrity

and strength as well as methods of estimating treatment effects are crucial to

program evaluation to assess whether the lack of successful outcomes results

from problems in program implementation (Hall and Loucks 1977; Quay 1977;

Sechrest et al. 1979; Chen and Rossi 1980; Rezmovic 1986; Peterson and

Bickman 1988; Reid and Hanrahan 1988). Furthermore, without specific

information on the nature of a program, studies with positive outcomes cannot

clearly explain why they were obtained and programs cannot be readily

replicated (Simpson 1988).

To date, the most widely discussed aspect of the substance abuse treatment

process consists of differentiating the major treatment modalities (Simpson

1988; Allison and Hubbard 1985). There is very little study of treatment

process variations within each type of modality, particularly in long-term

therapeutic communities (Cole and James 1975; De Leon 1988; Allison and

Hubbard 1985).

Triangulated measures in this evaluation will obtain perceptions of the

program structure and process from the perspective of inmate participants,

program staff, and researchers, using such instruments and data sources

as the following:

1.

2.

3.

The Program Description Checklist. This checklist will be used to obtain

staff perceptions of various program aspects, including types of services,

emphasized program goals, treatment planning process, program

termination, level of inmate involvement, and staff background. It is

adapted from the Program Description Checklist used by Hubbard and

colleagues (1989) in TOPS.

The Moos Community-Programs Environment Scale (COPES). This scale

will be used to obtain inmate perceptions of 10 dimensions of the treatment

program environment. COPES has been used to assess various treatment

program climates (Price and Moos 1975; Fischer 1979; Verinis 1983; Bell

1985; Friedman et al. 1986).

Therapist Empathy Scales. Psychotherapy outcome studies consistently

find that higher levels of therapist empathy and understanding are

associated with positive client outcomes (Cooley and Lajoy 1980; Valle

1981; Free et al. 1985; Orlinsky and Howard 1986). Items will be selected

267
4.

5.

6.

7.

from therapist empathy scales, such as the Barrett-Lennard (1962)

Relationship Inventory and the Cooley and Lajoy (1980) instrument

representing five factors of client-therapist relationships.

Client Satisfaction Questionnaire (CSQ). A modified version of the

CSQ developed by LeVois and colleagues (1981) will be used to assess

satisfaction with staff and with the type, amount, and quality of services

received.

The Observer Checklist. A checklist has been developed to obtain

information about program operations from a third perspective, that

of research staff not affiliated with program operations. In addition to

recording information on attendance, adherence to program schedule,

the physical environment, and the extent of inmate participation, a

major focus of this instrument is on the nature and type of inmate-staff

interactions. Categorizations of these interactions are being adopted from

Levy’s (1979) research on the activities and processes occurring in selfhelp groups (e.g., behavioral prescriptions, modeling, behavioral rehearsal,

self-disclosure). Both inmate and staff behavior will be rated.

Services Received. Data will be extracted from BOP and transitional

services program records on treatment plans, type and frequency of

psychological services received, and attendance failures for each

research subject. Services received will include those within residential

drug treatment programs as well as drug education, Narcotics Anonymous,

Alcoholics Anonymous, and other psychological or counseling services.

Prison Social Climate Survey (PSCS). Perceptions of staff and inmates

at institutions with residential drug treatment programs will be obtained

before and after program startup using the PSCS. This instrument

measures various aspects of the prison environment about which prison

administrators express concern: security and safety, living conditions,

programs and services, and personal well-being (Saylor 1984). Data from

the surveys will be used to assess the effect, if any, of the drug abuse

treatment programs on each institution as a whole and, conversely, to

assess the effect of the institution environment on drug treatment program

participants.

Postrelease Environment. Outcome studies and studies of natural recovery

processes from addiction have identified similar postrelease factors conducive

to preventing drug use relapse. These factors include participation in a social

network that does not use drugs or that is supportive of the individual’s efforts

to stop using drugs, family responsibilities, involvement in leisure or recreational

268
activities that do not involve the use of drugs, employment, absence of such

negative life events as a death in the family or legal problems, and positive

emotional states (Cronkite and Moos 1980; Finney et al. 1981; Hawkins 1983;

Jorquez 1983; Rhoads 1983; Catalano and Hawkins 1985; Perri 1985; Simpson

and Marsh 1986; Faupel 1988). In addition, others note that involvement in

criminal and/or drug-abusing subcultures as well as labor force participation

may be affected by the community structure within which an individual resides

(Sells et al. 1977; Hawkins 1983). Indicators of the community structure include

unemployment rates, economic conditions, income levels, drug-related arrest

rates, other arrest rates, and availability of treatment resources. This evaluation

will include both these microlevel and macrolevel indicators of postrelease

environment.

Dependent Variable Measures

Proximal Outcomes. The proximal outcomes consist of two types. The

first type is composed of indicators of adjustment while participating in the

drug treatment programs, either during the in-prison component or during

the transitional service phase. Dimensions of adjustment will include rule

infractions; “dirty” urines; and participation in institutional vocational,

educational, and recreational programs. The second type of proximal

outcome addresses the theoretical assumptions of the relapse prevention

model and consists of pre-post change scores on the instruments assessing

perceptions about drug use.

Distal Outcomes. The primary distal outcomes of interest are drug use and

criminal activities in that (1) a primary goal of drug treatment programs is to

prevent drug use subsequent to release; (2) prison administrators are interested

in reducing recidivism; and (3) research has demonstrated a link between drug

abuse and criminal behavior. Other outcome measures of interest include

social and occupational functioning as well as mental and physical health.

The followup interviews elicit information similar to that obtained in the program

intake interviews to enable pretreatment and posttreatment comparisons. In

addition, special attention will focus on specific aspects of outcome measures.

First, resumption of drug use will allow for distinctions between lapses-any

instance of return to drug use-and relapse, a resumption of regular baseline

drug use. Second, information on the circumstances surrounding drug use and

criminal activity afler release from prison will be collected. This information is

important to understanding the processes of relapse and rehabilitation and may

provide useful feedback to program staff for program modifications (Wells et al.

1988b).

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The 5-year followup period is of sufficient length to indicate whether treatment

effects endure over time. Followup interviews will be administered at three

points after release from BOP custody: 3 to 6 months after release, 2 years

after release, and 5 years after release. The first followup interview time frame

was selected on the basis of previous research demonstrating that most

individuals relapse within the first 6 months of program termination (Tims and

Leukefeld 1988).

Conceptual Model

The proposed research will be guided by the following conceptual model

(figure 1) identifying the general classes of variables to be used in data

analysis. Although previous research suggests that each class of variables

may affect the distal outcomes of interest, comprehensive assessments with a

longitudinal database on the relative effects of each class of variables on the

ultimate outcomes have been infrequent. Inmate background and demographic

characteristics as well as psychological/cognitive characteristics at program

admission are seen as having an effect on the distal outcomes. However,

these effects may be mediated by both the in-prison and the community drug

treatment components, proximal outcomes that reflect changing cognitive

and psychological characteristics of individuals, and, finally, the postrelease

environment. In addition, this model will serve as a basis for generating specific

hypotheses about the relationship between and within classes of variables.

Data Analysis

This evaluation will use a variety of multivariate analytic techniques that seldom

have been used in previous drug treatment outcome studies but recently have

been shown to be of value in answering questions about which treatment is

effective for which types of individuals and in addressing such issues as time

to relapse (Speckart and Anglin 1986; Jaffe 1988). These multivariate

techniques will provide the means to control for confounding factors when

comparing treatment groups with nonequivalent comparison groups and will

promote external validity.

A variety of techniques will be used to address different questions. For

example, Grade of Membership (GOM) analysis, a recently developed

multivariate analytical model that overcomes many problems of cluster

analysis (Woodbury and Manton 1982; Swartz et al. 1986), will be used to

identify types of drug abusers. Discriminant analysis will be used to identify

the factors differentiating treatment successes from treatment failures.

270
FIGURE 1. The influence of background and psychological/cognitive

characteristics and treatment experiences on treatment outcomes

Of particular importance will be event history analysis (Allison 1984) and

survival techniques to address questions about duration of time until relapse

(Barton and Turnbull 1981; Anglin and Fisher 1987; Curry et al. 1988;

Greenhouse et al. 1989). Hazard functions will be used to identify the

posttreatment intervals during which individuals are at highest risk for relapse

and those associated with a propensity to relapse at different time points.

Survival function analyses will be used to compare differences in survival

among the various treatment groups.

SPECIAL ISSUES IN EVALUATING PRISON DRUG TREATMENT

PROGRAMS

The evaluation of prison-based treatment programs present special issues

related both to data collection and to program implementation. All data

collected after release from the custody of BOP should be conducted by

nonprison personnel to ensure that respondents perceive followup interviews as

confidential. Since program enrollment occurs toward the end of an individual’s

sentence, there are concerns about accurate recall of life event history prior to

incarceration. Also problematic are adequate categorization and description of

the treatment process for the large number of transitional treatment services to

which subjects will be released.

271

318-269 0 - 92 - 11 QL3
Given that dropout rates in many drug treatment programs historically have

been high and that program retention is correlated with positive outcomes,

a crucial issue in prison drug treatment may be intervention timing. BOP’s

program design will not permit testing models of earlier intensive intervention for

individuals with longer sentences. How are questions answered concerning the

best time for intervening within a prison setting? How much does the process of

adapting to prison life interfere with possible program participation (i.e., having

to transfer away from an institution that is close to family to participate in drug

treatment). Questions also may be raised about the program implementation

constraints within a prison setting with respect to practicing skills of resisting

drug use in ‘tempting” situations that would occur outside the prison context.

In summary, the research design for evaluating BOP’s residential drug

treatment programs will provide information of interest to both criminal justice

and drug control policymakers. The information will increase the knowledge

base concerning the specific issue of effective prison drug programs as well as

the more general issue of what works with whom. The selection of measures

and data analytic techniques represents an integration of measurement issues

within the framework of a comprehensive theoretical orientation. The authors

hope to begin to address the question of who requires intensive long-term

treatment, who requires only minimal treatment, who can change on their own,

and who will not change.

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AUTHORS

Bernadette Pelissier, Ph.D.

Research Analyst

Federal Bureau of Prisons

Research Department

Federal Correctional Institution

P.O. Box 1000

Butner. NC 27509

Dan McCarthy, M.A.

Research Analyst

Office of Research and Evaluation

Federal Bureau of Prisons

NALC Building, Room 202

320 First Street, N.W.

Washington, DC 20534

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Directions for Practice and Research

Carl G. Leukefeld and Frank M. Tims

INTRODUCTION

Many drug abusers come into contact with the criminal justice system through

jails and lockups. The impressions of those who work in prisons and jails are

supported with data from the Drug Use Forecasting (DUF) system. DUF reports

show that approximately 60 percent of arrestees in 22 major cities were using a

drug other than alcohol at the time of their arrest (Wish and O’Neil 1989). In

fact, the criminal justice system is awash with drug users, and the need for

expanding drug abuse treatment in prisons and jails has been identified.

Prison treatment for drug abuse has a varied history in the United States.

Treatment for incarcerated Federal offenders formally began with two U.S.

Public Health Service (PHS) Hospitals that were opened in Lexington, KY, in

1935 and Fort Worth, TX, in 1938. It is interesting to note that the need for

these Federal treatment facilities first was recognized by the Director of the

Federal Bureau of Prisons (BOP), who urged Congress to establish narcotics

farms in these locations. These facilities evolved from farms to hospitals to

clinical research centers that were transferred from PHS and are now part of

BOP.

Drug abuse treatment in prisons has been influenced by the therapeutic

community (TC) movement, which incorporates former drug users who provide

a structured therapeutic environment within a prison. However, prison drug

abuse treatment currently is limited, partly because of the atmosphere that

resulted from the antirehabilitation research findings published in the late 1960s

(Martinson 1974). Treatment for drug abusers in jails is even more limited,

which should be expected given the brief length of stay (Peters and May, this

volume).

People who become aware of the limited, but currently expanding, drug abuse

treatment programs in the Nation’s prisons initially are shocked; then they ask

the question, “Why?” The answer is complicated by both policy and science

issues. The science issues may be easier to describe than related policy

issues, but they also are complicated. Lipton and colleagues’ review (this

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volume), also called the Matineson report (1974) reaffirmed the backlash of

antirehabilitation and then concluded after reviewing available research from

correctional rehabilitation studies that rehabilitation efforts did not work.

Although this interpretation subsequently was reversed after additional study,

the report’s influence on rehabilitation programs as well as on drug abuse

treatment in prisons and jails was enormous. New treatment programs were

not begun, and some existing treatment and rehabilitation programs were

terminated (Murray, this volume).

The current reemphasis on drug abuse treatment in prisons and jails appears

to be motivated by the need to do something about the large numbers of drug

abusers in prisons and supported by recent research findings that drug abuse

treatment is effective (Hubbard et al. 1989). The effectiveness of drug abuse

treatment is related specifically to the length of time an individual remains in

drug abuse treatment, regardless of the type of treatment; however, it also

is known that drug abuse is both chronic and relapsing once a person is

addicted. The chronicity and relapsing aspects of drug abuse often make the

effectiveness of drug abuse treatment difficult to understand. Viewed from a

health perspective, treatment should be followed by "cure” and no further drug

abuse. Viewed from a correctional perspective, recidivism should be reduced

and drug abuse ended. These goals are compatible but frequently are

implemented differently, often causing tension. There is also criticism about the

limitations of drug abuse treatment in spite of the research that has consistently

supported the effectiveness of drug abuse treatment generally (Hubbard et al.

1989) and, specifically, when combined with criminal justice sanctions

(Leukefeld and Tims 1988).

Experiences related to treating drug abusers in prisons and jails are largely from

the United States. Unfortunately, these experiences are related closely to the

rapid expansion of drug use, most recently crack cocaine, in larger cities and

the crime associated with it. These “epidemics” strain correctional facilities and

community treatment settings. The current recognition of the expanding drug

abuse problem provides criminal justice practitioners with a window of

opportunity to establish drug abuse treatment interventions that are

documented with research data and supported by practice. In fact, criminal

justice practitioners are recognizing the important control function that drug

abuse treatment can have in an institution, a major purpose for some and a

bonus for others. This monograph seeks to increase knowledge about drug

abuse treatment in prisons and jails. The utility of this information hopefully will

be short-lived given the expansion in drug abuse treatment initiatives that are

expected in the next several years. However, until those data are published,

this volume should provide useful information and guidance for practitioners

and researchers.

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This monograph focuses on examining drug abuse treatment in prisons and

jails within the context of acquired immunodeficiency syndrome (AIDS) and

the high levels of drug abuse in the criminal justice system. Its purpose is to

explore selected drug abuse treatment approaches, present evaluation findings,

review-related issues, including assessments, explore evaluation methodology,

and present recommendations for practice and research. The following

sections highlight the major topics included in the monograph. Chapters are

grouped in five areas: current status of drug abuse treatment in prisons and

jails, drug abuse treatment approaches, evaluations, special issues, and

recommendations.

CURRENT STATUS OF DRUG ABUSE TREATMENT IN PRISONS AND

JAILS

Lipton and colleagues (this volume) overview institutional drug abuse treatment

and examine the chronicity of drug abuse. They also point out that all but eight

States are under court order for prison overcrowding, with a 55-percent growth

rate in the prison population during the past 8 years. Unfortunately, limited

research evidence currently exists to support the effectiveness of drug abuse

treatment in prisons, including the most traditional forms of drug abuse

treatment such as drug education, self-help groups, individual counseling,

group counseling, and milieu therapy. However, TC research has shown

promise with positive outcomes from the Stay’n Out program (Wexler et al.,

this volume) and the Cornerstone program (Field, this volume).

Brown (this volume) presents five program models that are available for

incarcerated drug abusers in correctional settings: (1) no specialized services,

which is most typical; (2) drug education and/or drug abuse counseling;

(3) residential units dedicated to drug abuse treatment; (4) client-initiated and/or

maintained services; and (5) specialized services for drug abusers not directly

targeted on their drug abuse problems. He also discusses three service

delivery models that serve as alternatives to incarceration: (1) probation, a mix

of counseling, support, and surveillance, which is most typical; (2) surveillance,

which includes house arrest and electronic monitoring; and (3) diversion, which

is represented by Treatment Alternatives to Street Crime (TASC).

Our Nation’s jails provide a reservoir of drug abusers. A survey completed

by the American Jail Association examined the scope of drug abuse treatment

services in jails across the country (Peters and May, this volume). Of the

57 percent (n=1,737) of the jails who responded to a mailed questionnaire,

only 28 percent indicated that they offered drug abuse treatment in their jails.

Moreover, only 19 percent indicated that they funded drug treatment programs,

and only 12 percent of the drug treatment programs were isolated from the

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general jail population. In addition, the average jail drug treatment program

focused on whites (66 percent of program participants), had an average size

of 42 and an average age of 26, and employed three staff members; more than

80 percent had volunteer staff. Using data from the 1,687 jails that provided

inmate census information, only 6.7 percent of the average inmate population

was enrolled in drug treatment. A major conclusion reached by Peters and

May is the need for jails, especially for smaller jails, to develop liaison with

community drug abuse treatment programs.

The AIDS virus is a major problem in the Nation’s prisons and jails. However,

the number of human immunodeficiency virus (HIV)-1-positive individuals in

prisons is not as large as initially projected. There is speculation that AIDS

education may be more effective for this group than others. By October 1989,

5,411 cases of AIDS were reported from U.S. prisons and jails (Hammett 1990).

Seroprevalence rates also vary by region, with 7 percent in Maryland and 17.4

percent in New York. Vlahov (this volume) identifies three responses to HIV-1

in correctional settings: educating inmates at risk in correctional settings about

unlikely routes of transmission, with emphasis on intravenous drug use;

providing serological screening that focuses on inmate identification to start

confidential chemotherapeutic protocols (costs and benefits of such testing

must be weighed); and participating in drug abuse treatment to help intravenous

drug abusers decrease their needle use. Vlahov suggests that correctional

settings serve as an opportune environment to begin HIV treatment for these

difficult-to-reach individuals.

DRUG ABUSE TREATMENT APPROACHES

Murray (this volume) indicates that BOP, to intervene with the increasing

number of drug abusers, is expanding drug abuse interventions. Murray

reviews BOP’s history of providing treatment to drug abusers and then

describes contemporary issues. He points out that nearly 50 percent of the

56,500 BOP inmates in 60 facilities are incarcerated for drug-related crime; by

1995 this population will reach 95,000, with almost 70 percent incarcerated for

drug offenses. After reviewing select studies, Murray adds that addiction is a

multiplier of crime. With that background, he outlines BOP’s comprehensive

drug abuse treatment strategy, which includes a multitiered approach and a

comprehensive evaluation, described in this volume by Pelissier and McCarthy.

The BOP’s layered approach includes one level of drug education, three

treatment levels, and one level of transitional services: (1) drug education

programs that will be mandatory for inmates with a substance abuse history;

(2) individual, group, and self-help drug abuse counseling services that will be

available on an outpatient basis to volunteers; (3) comprehensive residential

drug treatment units, which began in October 1990; (4) three pilot drug abuse

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treatment programs with a research emphasis were operational by the end of

1990; and (5) transitional services for community reentry after release from

comprehensive and pilot residential programs.

Winett and colleagues (this volume) describe a pilot program for drug abusers

that is planned by the California Department of Corrections (CDC) to examine

the effectiveness of a TC intervention. This prison-based TC, called “Amity

Righturn,” will be located near San Diego, CA, and will serve 200 mediumsecurity male inmates for a 7- to 9-month residential experience. The need for

this pilot is supported with CDC intake statistics that show that the number of

drug offenders in California grew from 3,890 in 1984 to 19,909 in 1988. The

need also was supported by the recognition that in 1988 drug offense

commitments were for the first time the largest category of felony commitments

to the CDC. Righturn incorporates the most recent research findings and is

designed as a program evaluation activity. The outcome study will include

400 volunteers, with 200 randomly assigned to the Righturn program.

Approximately 100 participants, group 1, will parole to San Diego County and

receive community substance abuse treatment. Approximately 100 inmates,

group 2, will participate in the Righturn program and will receive regular parole

services somewhere in the State system. Group 3, composed of about 200

who are eligible and volunteer but are not randomly assigned to groups 1 or 2,

will serve as a control group. Results are expected to add knowledge related to

the effectiveness of prison-based and community drug abuse treatment.

Brenna (this volume) provides a different perspective of drug abuse treatment

by focusing on substance abuse services for juvenile offenders. The State of

Washington’s experience in treating juvenile offenders has developed within the

goals of offender accountability, coupled with rehabilitation. Based on this

explicit philosophy, the Washington model of integrated services evolved as a

continuum of services based on client dysfunction. The integrated service

model incorporates the following: (1) inpatient chemical dependency cottages

located on institutional campuses, (2) specially trained staff who coordinate and

provide treatment services, (3) specifically designed drug education provided by

the institutional school programs, (4) chemical dependency assessments by

diagnostic staff, and (5) onsite drug detection.

The Florida Department of Corrections has established a four-tiered approach

for their Comprehensive Statewide Substance Abuse Program. Bell and

coworkers (this volume) indicate that more than 50 percent of Florida’s inmates

admit to a serious substance abuse problem. They go on to describe Florida’s

Tiers program, which commences with an assessment to determine the severity

of substance abuse classification and to recommend a treatment level. Tier I is

a 40-hour program focused on providing educational drug abuse information for

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those who have a less than severe substance abuse history, deny having a

problem, and have a short sentence. Tier II is an intensive 8-week, residential

modified TC program for those diagnosed with a serious drug problem. Tier III

is residential TC treatment for 9 to 12 months in the community provided

through contract services for 54 beds available to those who meet work release

requirements. Tier IV is 10 weeks of community counseling, focused on relapse

prevention and supportive therapy for inmates assigned to community

correctional centers. These service providers contribute information to and

use information from the Substance Abusing Offender Treatment Information

Network for treatment management. In addition, three types of evaluations are

being carried out: screening and assessment to determine, among other things,

severity and treatment intervention; process evaluation for program integrity;

and outcome evaluation to examine knowledge, attitudes, and behaviors.

Vigdal and Stadler (this volume) emphasize the importance of providing a

system-wide approach to treating drug-abusing offenders. Using the Wisconsin

Department of Corrections as an example, they examine various strategies and

programs that support continuity of care. Wisconsin’s specialized substance

abuse programing began in 1975 with an alcohol treatment unit and with

demonstrated effectiveness (Vigdal et al. 1980). Within that context, the current

program evolved that includes the following: an Alternative to Revocation

component with 10 percent of the treatment beds reserved for offenders who

are being revoked and no community treatment is available; Special Treatment

Programs, one for alcohol and two for drugs other than alcohol; a residential TC

for 9 to 12 months; intensive supervision positions combined with drug testing

for five teams of two officers with a 40-person caseload for each team; and daytreatment programs, as an intermediate sanction, for coordinated care with

correctional treatment facilities. The heart of this systems approach is the

assessment procedures that are used to match treatments and offenders along

four dimensions: alcohol dependence, other drug involvement, psychiatric

impairment, and psychopathic tendencies.

Field (this volume) outlines the rich experience and evaluation findings Oregon

has had with innovative drug treatment services. The Cornerstone program,

located on the grounds of the Oregon State Hospital, is a 32-bed TC that

began in 1975. With Cornerstone as a model, the State currently funds three

additional TCs that also serve drug abuse offenders who are sex offenders,

mentally ill, and/or mentally or socially retarded. Oregon also supports the

following drug abuse interventions: two additional residential treatment

programs, correctional institutional group counseling through contracts with

community treatment professionals, several cooperative agreements for

community treatment, a pilot program with subsidy funds for releases who are a

poor risk, a demonstration project to examine coordinated community services,

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the use of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups,

alcohol and drug education classes for alcoholics and addicts, and institutional

information centers to assist inmate recovery. In addition, all inmates are

subject to random urine testing. Research results indicate that Cornerstone

clients showed, as a function of the treatment program, enhanced self-esteem,

reduced psychiatric symptomatology, increased knowledge in critical treatment

areas, reduced criminal activity, and reduced criminal recidivism (Field 1985).

Field (this volume) reports that four conclusions can be reached based on

220 different program admissions from 1983 to 1985: (1) Criminal activity

decreased for Cornerstone participants; (2) addicted offenders with little or no

treatment show accelerated criminal activity: (3) time in treatment is correlated

with decreasing criminal activity; (4) arrests, convictions, or prison

incarcerations are about equally accurate measures.

EVALUATIONS

Wexler and colleagues (this volume) present data from a study that examines

the Stay’n Out TC program in New York. Using a sample of 1,500 subjects

from the program, which has operated in New York’s correctional system for

more than 12 years, they report that prison-based TC treatment reduced

recidivism rates for males and females. A quasi-experimental design was used

to compare the Stay'n Out intervention with inmates who volunteered for the

program but never participated, participants in a counseling program, and

participants in a milieu therapy program. Parole outcomes are compared for

four groups of males and three groups of females (a female milieu treatment

comparison group was not available). Three parole outcome variables are

reported: the percent arrested, the mean time until first arrest for those

arrested, and the percent positively discharged. Based on these analyses, the

major finding is that the Stay’n Out TC was effective in reducing recidivism and

that this effect increased as time in the program increased but declined after 12

months. Positive parole completion, no arrest, and time until arrest increased

with time in the TC but did not increase for the other interventions.

Implementing and evaluating a prison drug treatment program can be

complicated by many things. lnciardi and coworkers (this volume) review

obstacles and present their experiences in implementing Delaware’s KEY TC

program. Some of the specific implementation issues cited are: a budget that

did not include adequate funds for program materials, support services, public

relations, and special events; the use of an initial facility that was neither

conducive to nor appropriate for a TC, which delayed implementation and

necessitated the selection of another facility; staff recruitment problems that rely

on a professional model and prohibit hiring ex-felon addicts; nonspecification of

client admission criteria; failure to develop close working relationships with the

285
Delaware Classification Board and other programs; lack of program autonomy;

and lack of aftercare services. Although the program is therapeutically driven

rather than research driven, a followup evaluation has started. An initial

analysis reveals that KEY residents are typically black, older, have had prior

treatment, and have used multiple drugs more than the general prison

population.

Methadone treatment has not been used by the criminal justice system.

Hubbard and colleagues (1989) report that only 3 percent of persons in

methadone treatment were referred by the criminal justice system, compared

with about 30 percent for outpatient drug-free and 30 percent for TC treatments.

In spite of that low referral rate, Magura and coworkers (this volume) present

research findings from a criminal justice methadone maintenance program

called Key Extended Entry Program (KEEP). KEEP was established in 1987

to provide methadone maintenance to addicts charged with misdemeanors at

Rikers Island in New York City and referral to community methadone programs

with dedicated treatment slots. Reporting on a long-term followup study that

includes a cohort of 225 KEEP participants and controls, Magura and coworkers

indicate that KEEP sociodemographic characteristics were similar to those of

other Rikers Island prisoners. They were daily cocaine users, more than half

(54 percent) of the injectors reported sharing needles or works in the previous 6

months, and property crimes were their most frequent arrest charge. There was

also a high attrition rate, 60 percent for men and 67 percent for women, for

those not in methadone treatment when released to community treatment.

SPECIAL ISSUES

Transition from institutional settings to the community is difficult for drug

offenders. Gregrich (this volume) explores issues related to managing the drugabusing offender and suggests that institutional crowding, caused by increasing

numbers of drug-abusing offenders, would be eased by community transition

programs and placements. Case management will receive additional attention

and could be held accountable for making the criminal justice system work—

a responsibility to be avoided. Clearly, there is no unifying voice for case

management, but there are advocates for community services, especially

now with planning for additional intermediate sanctions. In addition, Gregrich

posits several principles related to drug abuse treatment: Treatment and

coercion work together, drug abuse offenders are harder to treat than others,

interventions must focus on the chronic and related deviant behaviors, offender

and other drug treatment programs share certain characteristics, intensive

surveillance produces results, and interventions must be organized and

orthodox.

286
Continuing with the theme that drug abusers present special risks when they

are in transition from the institution to the community, Weinman (this volume)

suggests that this transition should follow a specific course that monitors drug

abuse and other behaviors. TASC, working together with parole, can intervene

successfully and systematically with the drug-abusing offender. Case

management through TASC incorporates the following elements: support,

staff training, data collection, client identification based on eligibility criteria,

assessment and referral, urinalysis, and monitoring. Weinman cites several

studies that indicate that TASC is successful, and she explores the benefits of

a TASC and parole partnership to help avoid prison crowding. Weinman also

identifies four necessities (Gregrich and Weinman 1990) for drug offender

management-early identification, thorough assessment, substantial

monitoring, and unbroken contact-and concludes that these principles define

the TASC/parole partnership.

Fletcher and Tims (this volume) explore methodological issues, with emphasis

in four areas: treatment outcomes, treatment process, environmental/situational

factors, and transitional factors. Treatment outcome studies should focus on

specific questions for behavioral change and optional treatment. Treatment

process studies should examine which treatment produces behavioral change

as well as how treatment can be improved. Environmental/situational factors

should incorporate the influence of prison contexts on treatment process and

outcomes. Transitional factors, including treatment carryover from the

institution to the community and how well institutional treatment prepares

inmates for community reentry, should be taken into account. Finally, Fletcher

and Tims remind us that research frequently is carried out in a hostile research

environment.

Pelissier and McCarthy (this volume) describe BOP’s drug abuse treatment

evaluation study. The design is a four-group, multisite assessment of

residential treatment. Eligible inmates will be assigned randomly to: group 1,

high-intensity pilot program; group 2, comparison group with no further in-prison

treatment; group 3, comparison group of moderate intensity residential

treatment; and group 4, matched sample, nonvolunteer comparison group.

Independent variable measures include sociodemographic characteristics:

cognitive/psychological attributes such as psychological impairment, motivation,

and cognition about substance abuse; treatment structure and process; and

postrelease environment. Dependent variables will include proximal outcomes

such as adjustment measures (e.g., rule infractions, dirty urines, and

participation in institutional programs) and drug use perceptions to test

theoretical assumptions. Distal outcomes include drug use and criminal

activities, recidivism, social and occupational functioning, and mental/physical

health.

207
RECOMMENDATIONS

The following statements represent areas of agreement reached by the group

of criminal justice practitioners and researchers with extensive experience in

correctional drug abuse treatment who attended the National Institute on Drug

Abuse technical review on “Drug Abuse Treatment in Prisons and Jails.” The

most intense discussion focused on the type and extent of need for drug abuse

treatment in correctional settings as well as the types of treatment interventions

that should be available to drug abusers in prisons and jails. In addition,

staffing drug abuse treatment activities with former abusers or professionals

was reviewed as a possible anchor point on a continuum: a middle ground of

combining staff was deemed most viable. The specific points of agreement

were as follows:

Treatment Interventions

—A continuum of treatment program options, balanced between

institutional and community-based treatment interventions, should be

available for drug-abusing offenders.

—The unique needs of special population groups, including women and

minority offenders, should receive special attention.

—Successful correctional drug abuse treatment programs must have

commitment from top administrators and others throughout the relevant

organizations.

—If programmatic compromises, based on limited and competitive

resources, are necessary, then evaluation data should be used to

develop cost-efficient and integrated service models.

—Program goals should be established that incorporate the primary

objective of reducing criminal activity and drug abuse as well as

reducing recidivism with secondary or interim objectives of reducing

criminal activity and managing inmate behavior. Emphasis should be

placed on joint custody within a framework of healing and punishing.

—Although assessment and diagnosis are key to good programing,

assessments should be balanced with needed and available treatment

services.

—New and innovative service models must be developed and evaluated.

288
—Drug testing should be part of correctional drug abuse treatment.

—It is suggested that a drug treatment program be isolated physically from

the general prison or jail population and that treatment also be available

to the general prison population.

—Correctional drug abuse treatment initiatives for juveniles, which are

different from adult drug abuse treatment, need to be developed and

expanded.

—Modeling is an important component of drug abuse treatment, and

recovering persons have been successful in correctional drug abuse

treatment programs.

—Aftercare services should be more than self-help activities (e.g., AA and

NA).

—Although TCs are widely used in prisons and jails for the treatment of

drug abusers, TC treatment is not the only successful approach to be

used in these settings and is not appropriate for all offenders.

—Educational and vocational services should be available.

—Transition from prison to community programs should be emphasized,

including relapse prevention approaches.

Research

—A historical review of past programmatic efforts using meta-analytic

procedures should be initiated to clarify the impact of correctional drug

abuse treatment programs.

—To facilitate planning, comprehensive epidemiological studies should be

initiated with uniform measurement criteria to examine current patterns

and project future patterns of drug abuse.

—A standardized correctional drug abuse treatment topology should be

developed that incorporates uniform definitions of treatment and system

components (i.e., assessment, education, intervention, treatment, and

continuity of care).

—A series of studies should be initiated to develop consistent outcome

measures across sites with an eye to developing operational program

performance standards.

289
—A survey of correctional and community programs focused on drug

abuse interventions would clarify the existing universe of services as well

as identify new intervention approaches.

—Further studies of the economic impact of drug abuse on crime should

be initiated.

—A series of studies should be carried out that would examine the

relationship of sequencing surveillance with drug abuse treatment

combined with either probation or parole.

Evaluation

—Program evaluation information and feedback must be given as quickly

as possible to intervention staff because evaluation information can

help staff members better understand their interventions and provide

guidance for program modifications.

—A large-scale and multisite program evaluation should be initiated to

examine the long-term efficacy of correctional drug abuse treatment

efforts, including institutional and community interventions.

—Treatment comparison and control groups, randomized if possible,

should be incorporated into evaluation designs.

—Study dropouts and those persons entering correctional drug abuse

treatment programs should be taken into consideration when outcome

data are analyzed.

—Quasi-experimental designs with “wait list” controls are a realistic

possibility when evaluating correctional drug abuse treatment programs.

—Longitudinal and nested evaluation designs should be initiated to clarify

the efficacy of interventions and to better understand drug abuse and

criminal careers.

—Evaluation efforts within correctional environments should be planned to

take into account such factors as the impact of wellness activities and

religious beliefs.

—Studies should be initiated to better understand correctional system

dropouts and failures as well as those who refuse treatment.

290
—Special studies should be initiated to examine the impact of prison drug

abuse treatment on long-term inmates.

—Ethnographic studies should be incorporated into evaluations along with

systematically reported anecdotal information.

Demonstrations

—Replicable drug abuse treatment demonstration programs should be

initiated in all phases of the criminal justice system.

—Demonstration programs should be initiated to examine the feasibility of

establishing model drug abuse treatment initiatives. Such demonstration

programs should combine staff training activities for prison facilities that

are combined with community-based treatment programs.

Management Information

—A standardized management information system should be developed to

provide uniform data for decisionmaking and program evaluation. This

information also could be used to garner support from policymakers and

to provide uniform data points across all components.

Community Linkage

—Citizen advisory groups should be established to provide suggestions

and policy input for correctional drug abuse treatment programs.

—Additional emphasis must be placed on presenting the positive aspects

of correctional drug abuse treatment to consumers and to the general

public.

—Joint and interagency linkages, designed to enhance drug abuse

interventions, should be developed at all levels.

Training

—As drug treatment is expanded in jails and prisons, additional personnel,

including former users, correctional officers, and professionals, must be

cross-trained and jointly trained to provide drug abuse treatment.

—Training capacity and uniform training standards should be developed for

correctional drug abuse treatment practitioners.

291
—Internships and research training should be available to encourage a

new generation of researchers who are interested in and committed to

correctional research and evaluation in the area of drug abuse.

Technical Assistance

—A centralized and ongoing technical assistance effort should be

established and standardized criteria developed pertaining to client

variables, program variables, process variables, and outcome

measures for correctional drug abuse settings•

Funding

—Adequate funding should be stable and consistent to provide

institutional drug abuse treatment linked with community treatment.

REFERENCES

Field, G. The Cornerstone program: A client outcome study. Fed Probation

49(2):50-5, 1985.

Gregrich, R.J., and Weirman, B.A. “Managing the Dug Offender.” Paper

presented at the Academy of Criminal Justice Sciences, Denver, CO, March

13, 1990.

Hammett, T.M. Update 7989: AIDS in Correctional Facilities. Washington, DC:

National Institute of Justice, 1990.

Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Cavanaugh, E.R.; and Ginzburg,

H.M. Drug Abuse Treatment: A National Study of Effectiveness. Chapel

Hill, NC, and London: The University of North Carolina Press, 1989. 213 pp.

Leukefeld, C.G., and Tims, F.M., eds. Compulsory Treatment of Drug Abuse:

Research and Clinical Practice. National Institute on Drug Abuse Research

Monograph 86. DHHS Pub. No. (ADM)89-1578. Washington, DC: Supt. of

Docs., U.S. Govt. Print. Off., 1988. 258 pp.

Martinson, R. What works? Questions and answers about prison reform.

Public Interest 35:22-54, 1974.

Vigdal, G.L.; Stadler, D.W.; Goodrick, D.D.; and Sutton, D.J. Skills training in a

program for problem-drinking offenders: A one-year follow-up evaluation.

J Offender Counseling Services Rehabil 5(2):61-73, 1980.

Wish, E.D., and O’Neil, J.A. Drug Use Forecasting (DUF) Research Update,

January to March, 7989. Washington, DC: National Institute of Justice,

1989.

292
AUTHORS

Carl G. Leukefeld, D.S.W.

Director

Center on Drug and Alcohol Research

University of Kentucky

210 Medical Annex 2

Lexington, KY 40536-0080

Frank M. Tims, Ph.D.

Deputy Branch Chief

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room 10A5600 Fishers Lane

Rockville, MD 20857

293
While limited supplies last, single copies of the monographs may be obtained

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availability of coming issues and other publications of the National Institute on

Drug Abuse relevant to drug abuse research.

Additional copies may be purchased from the U.S. Government Printing Office

(GPO) and/or the National Technical Information Service (NTIS) as indicated.

NTIS prices are for paper copy; add $3 handling charge for each order.

Microfiche copies are also available from NTIS. Prices from either source are

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Addresses are:

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(301) 468-2600

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For information on availability of NIDA Research Monographs 1 through 70

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Education Branch, Room 10A-54, 5600 Fishers Lane, Rockville, MD 20857.

294
71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M.

Brown, Ph.D.; Doris H. Clouet, Ph.D.; and David P. Friedman, Ph.D., eds.

GPO out of stock NTIS PB #89-151955/AS $31

72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims, Ph.D.,

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76 PROBLEMS OF DRUG DEPENDENCE, 1986: PROCEEDINGS OF THE

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OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

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77 ADOLESCENTDRUGABUSE: ANALYSESOFTREATMENT

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79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS.

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80 NEEDLE SHARING AMONG INTRAVENOUS DRUG ABUSERS:

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81 PROBLEMS OF DRUG DEPENDENCE, 1987: PROCEEDINGS OF THE

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82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D., and

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83 HEALTH HAZARDS OF NITRITE INHALANTS. Harry W. Haverkos, M.D.,

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84 LEARNING FACTORS IN SUBSTANCE ABUSE. Barbara A. Ray, Ph.D.,

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85 EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE. Raquel A. Crider,

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86 COMPULSORY TREATMENT OF DRUG ABUSE: RESEARCH AND

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87 OPIOID PEPTIDES: AN UPDATE. Rao S. Rapaka, Ph.D., and Bhola N.

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88 MECHANISMS OF COCAINE ABUSE AND TOXICITY. Doris H. Clouet,

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89 BIOLOGICAL VULNERABILITY TO DRUG ABUSE. Roy W. Pickens,

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91 DRUGS IN THE WORKPLACE: RESEARCH AND EVALUATION DATA.

Steven W. Gust, Ph.D., and J. Michael Walsh, Ph.D., eds.

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92 TESTING FOR ABUSE LIABILITY OF DRUGS IN HUMANS. Marian W.

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93 AIDS AND INTRAVENOUS DRUG USE: FUTURE DIRECTIONS FOR

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96 DRUGS OF ABUSE: CHEMISTRY, PHARMACOLOGY, IMMUNOLOGY,

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97 NEUROBIOLOGY OF DRUG ABUSE: LEARNING AND MEMORY. Lynda

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102 ANABOLIC STEROID ABUSE. Geraline C. Lin, Ph.D., and Lynda Erinoff,

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103 DRUGS AND VIOLENCE: CAUSES, CORRELATES, AND

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104 PSYCHOTHERAPY AND COUNSELING IN THE TREATMENT OF

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105 PROBLEMS OF DRUG DEPENDENCE, 1990: PROCEEDINGS OF THE

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OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

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106 IMPROVING DRUG ABUSE TREATMENT. Roy W. Pickens, Ph.D.; Carl

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107 DRUG ABUSE PREVENTION INTERVENTION RESEARCH:

METHODOLOGICAL ISSUES. Carl G. Leukefeld. D.S.W., and William J.

Bukoski, Ph.D., eds.

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108 CARDIOVASCULAR TOXICITY OF COCAINE: UNDERLYING

MECHANISMS. Pushpa V. Thadani, Ph.D., ed.

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298
109 LONGITUDINAL STUDIES OF HIV INFECTION IN INTRAVENOUS

DRUG USERS: METHODOLOGICAL ISSUES IN NATURAL HISTORY

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110 THE EPIDEMIOLOGY OF COCAINE USE AND ABUSE. Susan Schober,

Ph.D., and Charles Schade, M.D., M.P.H., eds.

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111 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH:

VOLUME I. Theresa N.H. Lee, Ph.D., ed.

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112 EMERGING TECHNOLOGIES AND NEW DIRECTIONS IN DRUG

ABUSE RESEARCH. Rao S. Rapaka, Ph.D.; Alexandros Makriyannis, Ph.D.;

and Michael J. Kuhar, Ph.D., eds.

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113 ECONOMIC COSTS, COST-EFFECTIVENESS, FINANCING, AND

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114 METHODOLOGICAL ISSUES IN CONTROLLED STUDIES ON

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115 METHAMPHETAMINE ABUSE: EPIDEMIOLOGIC ISSUES AND

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116 DRUG DISCRIMINATION: APPLICATIONS TO DRUG ABUSE

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117 METHODOLOGICAL ISSUES IN EPIDEMIOLOGICAL, PREVENTION,

AND TREATMENT RESEARCH ON DRUG-EXPOSED WOMEN AND THEIR

CHILDREN. M. Marlyne Kilbey, Ph.D., and Khursheed Asghar, Ph.D., eds.

299

U.S. GOVERNMENT PRINTING OFFICE : 1992 0 - 318-269 QL3

DHHS Publication No. (ADM) 92-1884

Alcohol, Drug Abuse, and Mental Health Administration

Printed 1992