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Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality & Addiction Research, Training & Application (CCARTA)

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Presentation on theme: "Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality & Addiction Research, Training & Application (CCARTA)"— Presentation transcript:

1 Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality & Addiction Research, Training & Application (CCARTA) Treatment of Substance Involved Offenders in Criminal Justice Settings – Challenges & Outcomes

2 Let’s start with some bad news

3 California Statistics 172,785 in prison (1986: 39,373) 172,785 in prison (1986: 39,373) Cost – $ per inmate Cost – $ per inmate 117,136 on parole (1986: 19,780) 117,136 on parole (1986: 19,780) Cost - $ per parolee Cost - $ per parolee 77% of males and 83% of females incarcerated in California have drug and alcohol problems. 77% of males and 83% of females incarcerated in California have drug and alcohol problems.

4 Nationwide cost Columbia University Report, March 2005 $ 30 billion states spent on adult corrections (incarceration, probation, parole) $24.1 billion of it was on substance involved offenders

5  During the 1980s and 1990s, the number of incarcerated women tripled, while the number of men doubled.  80% of these women have substance abuse problems. On Women… “What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000

6 Some Other Sad Facts Over 2 million inmates inhabited U.S. jails & prisons Over 2 million inmates inhabited U.S. jails & prisons They are parents of 3.4 million children They are parents of 3.4 million children 2 in 3 convicts have been tested positive for drugs at time of arrest. 2 in 3 convicts have been tested positive for drugs at time of arrest. 2 in 3 inmates have verified drug histories, 2 in 3 inmates have verified drug histories,BUT… Under 15 % receive systematic treatment Deitch, Koutsenok & Ruiz, 2004

7 Recidivism Within 12 months after release from custody % of substance involved offenders are back to institutions Within 12 months after release from custody % of substance involved offenders are back to institutions It is clear that criminal-justice sanctions by themselves do not reduce recidivism in this population It is clear that criminal-justice sanctions by themselves do not reduce recidivism in this population Prisons do manage behaviors, but do not shape behaviors Prisons do manage behaviors, but do not shape behaviors

8 Policies for Drug Offenders DiversionIncarceration Probation w/o verdict (Prop 36) Drug Courts Intermediate sanctions

9 Policies for Drug Offenders DiversionIncarceration Probation w/o verdict (Prop 36) Drug Courts Intermediate sanctions Public Safety Risks

10 Policies for Drug Offenders DiversionIncarceration Probation w/o verdict (Prop 36) Drug Courts Intermediate sanctions $$$$$$ Costs $$$$$$$$$ Public Safety Risks

11 Policies for Drug Offenders DiversionIncarceration Probation w/o verdict (Prop 36) Drug Courts Intermediate sanctions Over-reliance

12 Prison Criminal Recidivism in 3 Years 68% re-arrested 68% re-arrested 47% convicted 47% convicted 50% re-incarcerated 50% re-incarcerated Relapse to Drug Use in 3 Years 95% relapse 95% relapse Marlow D., Treatment Research Institute, 2006

13 Policies for Drug Offenders DiversionIncarceration Probation w/o verdict (Prop 36) Drug Courts Intermediate sanctions

14 Policies for Drug Offenders DiversionIncarceration Probation w/o verdict (Prop 36) Drug Courts Intermediate sanctions Over-reliance

15 Referral to Treatment 50% - 67% don’t show for intake 50% - 67% don’t show for intake 40% - 80% drop out in 3 months 40% - 80% drop out in 3 months 90% drop out in 12 months 90% drop out in 12 months 70% of probationers and parolees drop out within months 70% of probationers and parolees drop out within months Attrition D. Marlow D. & T.McLellan, TRI, 2004

16 Time for some better news What will happen if we combine incarceration and treatment?

17 From the work of Douglas B. Marlowe, J.D., Ph.D. Types of Substance Involved Offenders

18 Criminogenic Risks Age during rehabilitation < 25 years Age during rehabilitation < 25 years Criminal onset < 16 years Criminal onset < 16 years Prior rehabilitation failures Prior rehabilitation failures History of violence History of violence Antisocial Personality Disorder Antisocial Personality Disorder Psychopathy Psychopathy Familial history of crime Familial history of crime Criminal associations Criminal associations

19 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction

20 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms

21 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms } Abstinence is a distal goal

22 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Drug Abuse or Misuse Drug Abuse or Misuse } Abstinence is a distal goal

23 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Drug Abuse or Misuse Drug Abuse or Misuse } Abstinence is a distal goal Abstinence is a proximal goal }

24 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Drug Abuse or Misuse Drug Abuse or Misuse Collateral needs Collateral needs –E.g., dual diagnosis, HIV+ } Abstinence is a distal goal Abstinence is a proximal goal }

25 Criminogenic Needs Drug Dependence or Addiction Drug Dependence or Addiction 1.Binge pattern 2.Cravings or compulsions 3.Withdrawal symptoms Drug Abuse or Misuse Drug Abuse or Misuse Collateral needs Collateral needs –E.g., dual diagnosis, HIV+ } Abstinence is a distal goal Abstinence is a proximal goal }

26 High Risk Low Risk HighNeeds LowNeeds Risk & Needs Matrix

27 High Risk Low Risk HighNeeds LowNeeds Accountability &Treatment

28 Risk & Needs Matrix High Risk Low Risk HighNeeds LowNeeds Accountability &Treatment Treatment

29 Risk & Needs Matrix High Risk Low Risk HighNeeds LowNeeds Accountability &Treatment Treatment Accountability

30 Risk & Needs Matrix High Risk Low Risk HighNeeds LowNeeds Accountability &Treatment Treatment Prevention Accountability

31 Practice Implications High Risk Low Risk HighNeeds LowNeeds Frequent meetings with PA with PA Intensive treatment Intensive treatment Compliance is proximal Compliance is proximal Positive reinforcement Positive reinforcement Intensive treatment Intensive treatment Treatment is proximal Treatment is proximal Positive reinforcement Positive reinforcement Abstinence is proximal Abstinence is proximal Restrictive sanctions Restrictive sanctions Secondary prevention Secondary prevention Abstinence is proximal Abstinence is proximal

32 The profile of a successful high risk/high need client in community based therapeutic community is very similar to the one of a substance abusing offender in custody Why Therapeutic Community Model?

33 Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates Martin, Butzin, Saum, & Inciardi, 2001 (The Prison Journal) *p<.05

34 Texas In-prison TC Program : Return to custody rates (24 months follow-up), 2001 Aftercare Completers K. Knight, D. Simpson. The Prison Journal, 2002

35 California/Amity Program: 3-Year Return-to-Custody Rates (%) Wexler, Melnick, Lowe, & Peters, 2002 (The Prison Journal) *p<.001

36 Coercion in the Criminal Justice System A 2000 report from the Institute of Medicine summarized that “contrary to earlier fears among clinicians, criminal justice pressure does not threaten treatment effectiveness, and it improves outcomes”

37 Research Findings Multiple studies The length of time spent in treatment is a reliable predictor of post treatment outcomes and recidivism Coerced patients tend to stay longer and do as well as volunteers overall Most substance involved offenders would never seek treatment without pressure from the criminal-justice system

38 General Findings & Recommendations 1. Duration, Setting, Training: fundamental for In-prison TC (ITC) programs – –ITC = 9-12 months in a residential (segregated) treatment unit – –Staff training is a must – –On-going monitoring & evaluation 2. Engagement in transitional aftercare is crucial for effectiveness 3. ITC is most cost effective for high-risk offenders 4. Boot camps & periodic drug-focused counseling have poor outcomes Risk assessments should guide selections for treatment 5. Risk assessments should guide selections for treatment

39 Thank you


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