In Custody Treatment Rationale, Outcomes and Directions David A. Deitch, PhD Professor of Clinical Psychiatry University of California, San Diego Addiction Training Center
Dec 26, 2015
In Custody Treatment Rationale, Outcomes and
Directions
David A. Deitch, PhDProfessor of Clinical Psychiatry
University of California, San DiegoAddiction Training Center
Let’s start with some bad news
Type of Offense (June, 1997)
0.73.4
9.0
9.6
60.2
5.65.9 2.6
Drug Offenses Robbery Firearms, Explosives
Extortion Property Offenses ViolentImmigration White Collars
Illegal Drug Use Detected (UA+) Among Male Arrestees (in 23 Cities)*
656666686563
59 6266
36 36 3542 43
39394243
0
20
40
60
80
100
1991 1992 1993 1994 1995 1996 1997 1998 1999
% Any Drug % Cocaine
*Based on original 23 DUF cities; 1999 data for St. Louis not available.
Drug Arrests By Decade(FBI Crime Reports)
0.3% 0.7%
7.9%
36.9%
54.2%
63.7%
0%
10%
20%
30%
40%
50%
60%
70%
1941-50 1951-60 1961-70 1971-80 1981-90 1990-1999
State & Federal Inmates Needing vs Receiving Substance Abuse Treatment
552
74
587
107
627
121
688
150
749
130
801
168
840
149
0
100
200
300
400
500
600
700
800
900
1990 1991 1992 1993 1994 1995 1996
Need Trt Rec'd Trt(X 1000)
Nationwide costColumbia University Report, March 2003
$ 30 billion states spent on adult corrections (incarceration, probation, parole)
$24.1 billion of it was on substance involved offenders
During the 1980s and 1990s, the numberof incarcerated women tripled, while the number of men doubled.
80% of these women have substance abuse problems.)
On Women…
Sources: “What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000
Lifetime Chances of Going to Prison
BJS 2003
4.40.5
28.5
3.6
16.2
1.5
0
5
10
15
20
25
30
White Black Hispanic
Men Women
The Rise of Prison and Jail Populations Average Annual percent change
8.6
7
5.6
0.4
4.4
1.6
01
23
45
67
89
Federal Prisons State Prisons Local Jails
1999-2000 2000-2001
New Court Commitments Per 1,000 Arrests- Violent Offenses
460
700
229 266 233
365
56 780
100
200
300
400
500
600
700
800
Murder Forcible Rape Robbery Aggravatedassault
1990 2000
Property Offenses
160
193
24 28
72 71
103
79
34
77
0
20
40
60
80
100
120
140
160
180
200
Burglary Larceny/theft Motor vehicaltheft
Drug abuseviolations
Weaponsviolations
1990 2000
Parole Violators Returned to State Prisons
All New Court ParoleYear Admissions Commitments Violations
2001 586,273 360,251 209,636
Recent Change
1990- 27% 11% 57%2001
Why Incarceration Does Not Shape Behavior?
We want them to have self-worth
So we destroy their self worth
We want them to be responsible
So we take away all responsibility
We want them to be positive and constructive
So we degrade them and make them useless
We want them to be trustworthy
So we put them where there is no trust
We want them to quit exploiting usSo we put them where they exploit each other
We want them to be non-violentSo we put them where violence is all around
themWe want them to quit being the tough guy
So we put them where the tough guy is respected
We want them to quit hanging around losersSo we put all the losers in the state under one
roof
Common wisdom says that when you discover you are riding a dead
horse, the best strategy is to dismount. However, we often try
other strategies, including the following:
• Buy a stronger whip.• Change riders• Say things like “This is the way we always have ridden
this horse.”• Appoint a committee to study the horse.• Arrange to visit other sites to see how they ride dead
horses.• Create a training session to increase our riding ability.• Harness several dead horses together for increased speed.• Declare that “No horse is too dead to beat.”• Provide additional funding to increase the horse’s
performance.• Declare the horse is “better, faster, and cheaper” dead.• Study alternative uses for dead horses.• Promote the dead horse to a supervisory position.
Time for some better news
Why not treat them?
Three very important questions
• Is substance abuse treatment effective?
• What constitutes a successful treatment?
• How do we know it?
Social Criteria for Treatment SuccessDr. Jerome Jaffe
• Diminish crime in community
• Diminish tax consumptive behavior
• Diminish illicit substance abuse
• Increase tax productive behavior
• Increase personal well being
Criteria 1- Diminish crime in the community
0
10
20
30
40
50
60
70
1 year before 1 year post 5 years post
Methadone Maintenance Therapeutic Community Outpatient drug free
Criteria 2 – Diminish illicit drug use
0
10
20
30
40
50
60
70
80
1 year before 1 year post 5 years post
Outpatient Methadone Residential (TC) Outpatient drug free
Criteria 3 & 4- Diminish tax consumptive behavior (full time employment)
0
5
10
15
20
25
30
35
40
45
50
1 year before 1 year post 5 years post
Outpatient Methadone Residential (TC) Outpatient drug free
Criteria 5 – Increase Personal Well-Being (Suicidal Indicators)
0
5
10
15
20
25
30
35
40
45
50
1 year before 1 year post 5 years post
Outpatient Methadone Residential (TC) Outpatient drug free
90-Day Retention in Long-Term Residential Community Programs
by Treatment Readiness and Legal Pressure
27
38
51
34
4654
0
20
40
60
80
100
No Legal Pressure Legal Pressure
Low Readiness Moderate Readiness High Readiness
N=2194; Knight, Hiller, Broome, & Simpson, 2000 (JOR)
Probationer Response to Treatment(% with Problems in Psychological Functioning)
0
5
10
15
20
25
30
35
Intake Mid-Treatment At Discharge
AnxietySelf-esteemDepression
N=259; Knight & Simpson, 1994, Annual Report on 1993 SATF Intakes
It appears that the profile of a client in community based therapeutic community is
very similar to the one of a substance abusing offender in
custody
HighHigh(modified TC)(modified TC)
HighHigh(modified TC)(modified TC)
Key Issues
AftercareAftercare AftercareAftercare
SelectionSelection of of
TreatmenTreatment? t?
SelectionSelection of of
TreatmenTreatment? t?
ProblemProblemSeverity?Severity? ModerateModerate
(12-steps)(12-steps)ModerateModerate(12-steps)(12-steps)
LowLow(education)(education)
LowLow(education)(education)
Intensity Levels ?
2 of every 3Inmates haveUsed drugs
• EngagementEngagement• PerformancePerformance• OutcomesOutcomes
Historical Overview of Prison-Based Treatment Evaluations
27
41
29
74
26
63
28
64
0
20
40
60
80
% Arrested (2+ Years) Stay'n Out
% Imprisoned(3 Years)
Cornerstone
% Jailed (1 Year)
Amity
% Arrested (18 Months)
Key-Crest
Treatment
No treatment
In: Orientation to Therapeutic Community, 1998, Mid-America ATTC
Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates
71
95
72
83
45
73
31
65
No Treatment
(n=210)
ITC Dropout*(n=109)
ITC, but noAftercare*
(n=101)
ITC +Aftercare*
(n=69)
% with New Arrests% with Drug Use
Martin, Butzin, Saum, & Inciardi, 1999 (The Prison Journal)
*p<.05(adjusted
diff vs.No Trt)
California/Amity Program: 3-Year Return-to-Custody Rates (%)
7582 79
27
No Treatment
(n=189)
ITC Dropout(n=73)
ITC, but noAftercare(n=154)
ITC +Aftercare*
(n=162)
Wexler, Melnick, Lowe, & Peters, 1999 (The Prison Journal)
*p<.001
10
30
12
18
32
16
111
14
No Treatment
(n=58)
AftercareDropouts(n=101)
AftercareCompleters*
(n=123)
Year 3Year 2Year 1
Knight, Simpson, & Hiller, 1999 (The Prison Journal)
Texas/High-Severity Group: 3-Year Return-to-Custody Rates (%)
26
52
66
*p<.01
Texas/New Offenses Only: 3-Year Return-to-Custody Rates (%)
1922
6
NoTreatment
AftercareDropouts
AftercareCompleters
Knight, Simpson, & Hiller, 1999 (The Prison Journal)
SufficientSufficientRetentionRetentionSufficientSufficientRetentionRetention
Early Early EngagementEngagement
Early Early RecoveryRecovery
PosttreatmentPosttreatment
DrugDrugUseUse
DrugDrugUseUse
CrimeCrimeCrimeCrime
SocialSocialRelationsRelations
SocialSocialRelationsRelations
ProgramProgramParticipationParticipation
TherapeuticTherapeuticRelationshipRelationship
BehavioralBehavioralChangeChange
Psycho-SocialPsycho-SocialChangeChange
InmateInmateAttributesAttributes
InmateInmateAttributesAttributes
MotivMotiv
Evidence-Based Treatment Model
SupportiveSupportiveNetworksNetworks
SupportiveSupportiveNetworksNetworks
InductionInductionneeded?needed?
Simpson, 2001 (Addiction)
AftercareAftercare
Problems at Treatment Admission(TCU Self-Ratings at Intake in 1996)
26
30
42
39
57
27
20
Self-esteem
Depression
Anxiety
Childhood
Risk-taking
Hostility
Trt Readiness % of Probationers
N=409; Dees, Pitre, & Dansereau, 1997, Annual Report on 1996 Intakes
ChangesChangesover over time?time?
Hostility and Treatment Dropout Rates(% with high Hostility scores [4+ on 1-7 scale])
29
5052
242625
21
10
20
30
40
50
60
Intake Month 1 Month 3 Month 6
Dropouts (N=97/58)
Completers (n=290)
N=399; Broome et al., 2000, ACJS Conf Presentation (New Orleans)
-
-
+
+
Predictors of Early Engagement
PersonalPersonalInvolvementInvolvement
PsychosocialFunctioning at
Intake
Client Ratings at Month 1
N=399 ; Hiller et al., in progress, 1998 Wilmer admissions
BackgroundCharacteristics
PersonalPersonalProgressProgress
Trust inTrust inStaffStaff
AgeAgeAgeAge
FemaleFemaleFemaleFemale
Alcohol ProbAlcohol ProbAlcohol ProbAlcohol Prob
Coc ProbCoc ProbCoc ProbCoc Prob
+
SelfSelfEfficacyEfficacy
SelfSelfEfficacyEfficacy
AnxietyAnxietyAnxietyAnxiety
HostilityHostilityHostilityHostility
DesireDesirefor Helpfor HelpDesireDesire
for Helpfor Help
Multivariate Model of Early Dropout
(Stepwise Logistic Regression)
BackgroundBackgroundBackgroundBackground
Early Early DropoutDropout
Early Early DropoutDropout
PsychosocialPsychosocialPsychosocialPsychosocial
Odds Ratio=2.6
Odds Ratio=1.5
Odds Ratio=2.1
N=339; Hiller, Knight, & Simpson, 1999 (The Prison Journal)
High RiskHigh RiskHigh RiskHigh Risk
Low Self-efficacyLow Self-efficacyLow Self-efficacyLow Self-efficacy
UnemployedUnemployedUnemployedUnemployed
Multi-Site Predictors of Recidivism
RecidivismRecidivism
Hiller et al., 1999 (Addiction); Wexler et al., 1999 (CJB)
Younger AgeYounger Age
Previous ArrestsPrevious Arrests
ASP/HostilityASP/Hostility
Childhood ProblemsChildhood Problems
MotivationalMotivationalReadinessReadiness
MotivationalMotivationalReadinessReadiness
Trt SatisfactionTrt SatisfactionTrt SatisfactionTrt Satisfaction
AftercareAftercareCompletionCompletion
-
StrongestPredictors
Male New Admissions to Prison by Type of Offense with Tx Bed Growth
0
2000
4000
6000
8000
10000
12000
14000
16000
1997 1998 1999 2000 2001 2002
YEAR
Total # ofTx Beds
Drugs
Property
Person
Other
R.Krupp – CDC-OSAP, in press. 3/03
Female New Admissions to Prison by Type of Offense w ith Tx Bed Growth
0
500
1000
1500
2000
2500
3000
1997 1998 1999 2000 2001Year
Total # of TxBeds
Drugs
Property
Person
Other
Property
* Person
Other
R.Krupp – CDC-OSAP, in press. 3/03
Does In-Custody Therapeutic Community Have Any Impact
On Custody Staff?
Let’s find outLet’s find out
Inmate Rules Violation Reports(115’s)
408
67
265
101
322
79
166
61
Violence/Threat ofViolence
Non-violent DisruptiveBehavior
Failure to Program Grooming Standards
General Population Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al.
Inmate Rules Violation Reports(115’s)
1273
511
Serious 115's
General Population Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Use/Possession ofControlled Substances
• 45-50% of SAP inmates tested monthly
• Total u/a’s from April 1998 to March 2000:
15,221
• Total positive u/a’s:
24
• % of positive test results: 0.15%
National average is 4.8% (Camp&Camp, 2000)
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Sick Related Absenteeism(Sick Calls)
1234
522
General Population TreatmentIn: Corrections Compendium, 2001, Deitch, Koutsenok et al
Occupational Injuries(Documented Worker’s Comp)
1070
358
28
Related to Assaults Not Related to Assaults
General Population Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Effects of Treatment Environment on Custody Staff: Perception of Health
0
5
10
15
20
25
30
35
Excellent Very Good Fair Poor
General Pop. Treatment
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
Custody Staff - Perceptions of Job-related Stress (SATF-SAP)
In: Corrections Compendium, 2001, Deitch, Koutsenok et al
0
1
2
3
4
5
6
7
8
9
10
1 2 3 4 5 6 7 8 9 10
General Pop. TreatmentNo Stress High Stress
Treatment Benefits for Correctional Staff
• Greater job satisfaction• Improved working environment• Reduced job stress• Better physical and emotional health• Improved officer safety• Greater sense of accomplishment and
control• Added inmate management tools
General Findings & Recommendations
• Therapeutic Community appears to be the most effective treatment model for in-custody settings.
– Boot camps & periodic drug-focused counseling have poor outcomes
– Selective education, 12-step, cognitive-behavioral therapies & programs that use agonists (such as methadone) show promise
– Risk assessments should guide selections for treatment.
• TC model is most effective for high-risk cases.
General Findings & Recommendations (continued)
• Treatment works best if provided at end of sentence – pre release.
• Treatment works best if in separate housing areas.• Treatment works best with dedicated job
assignments.• If use “lifers” or long sentence inmates, job pay
title is important.• Engagement in transitional aftercare is crucial for
effectiveness.