2. In Custody Treatment Rationale, Outcomes and Directions David A. Deitch, PhD Professor of Clinical Psychiatry University of California, San Diego Addiction Training Center

3. Let’s start with some bad news

4. Type of Offense (June, 1997)

5. Illegal Drug Use Detected (UA+) Among Male Arrestees (in 23 Cities)* *Based on original 23 DUF cities; 1999 data for St. Louis not available.

6. Drug Arrests By Decade (FBI Crime Reports)

7. State & Federal Inmates Needing vs Receiving Substance Abuse Treatment (X 1000)

8. Nationwide cost Columbia University Report, March 2003 $ 30 billion states spent on adult corrections (incarceration, probation, parole) $24.1 billion of it was on substance involved offenders

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

10. Lifetime Chances of Going to Prison BJS 2003

11. The Rise of Prison and Jail Populations Average Annual percent change

12. New Court Commitments Per 1,000 Arrests- Violent Offenses

13. Property Offenses

14. Parole Violators Returned to State Prisons All New Court Parole Year Admissions Commitments Violations 2001 586,273 360,251 209,636 Recent Change 1990- 27%11% 57% 2001

15. 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

16. We want them to quit exploiting us So we put them where they exploit each other We want them to be non-violent So we put them where violence is all around them We 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 losers So we put all the losers in the state under one roof

17. 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:

18. 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.

19. Time for some better news Why not treat them?

20. Three very important questions Is substance abuse treatment effective? What constitutes a successful treatment? How do we know it?

21. Social Criteria for Treatment Success Dr. Jerome Jaffe Diminish crime in community Diminish tax consumptive behavior Diminish illicit substance abuse Increase tax productive behavior Increase personal well being

22. Criteria 1- Diminish crime in the community

23. Criteria 2 – Diminish illicit drug use

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

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

26. 90-Day Retention in Long-Term Residential Community Programs by Treatment Readiness and Legal Pressure N=2194; Knight, Hiller, Broome, & Simpson, 2000 (JOR)

27. Probationer Response to Treatment (% with Problems in Psychological Functioning) N=259; Knight & Simpson, 1994, Annual Report on 1993 SATF Intakes

28. 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

29. High (modified TC) High Key Issues Aftercare Aftercare Selection of Treatment? ProblemSeverity? Moderate(12-steps)Moderate(12-steps) Low(education)Low(education) Intensity Levels ? 2 of every 3 Inmates have Used drugs Engagement Engagement Performance Performance Outcomes Outcomes

30. Historical Overview of Prison-Based Treatment Evaluations In: Orientation to Therapeutic Community, 1998, Mid-America ATTC

31. Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates Martin, Butzin, Saum, & Inciardi, 1999 (The Prison Journal) *p<.05 (adjusted diff vs. No Trt)

32. California/Amity Program: 3-Year Return-to-Custody Rates (%) Wexler, Melnick, Lowe, & Peters, 1999 (The Prison Journal) *p<.001

33. Knight, Simpson, & Hiller, 1999 (The Prison Journal) Texas/High-Severity Group: 3-Year Return-to-Custody Rates (%) 26 52 66 *p<.01

34. Texas/New Offenses Only: 3-Year Return-to-Custody Rates (%) Knight, Simpson, & Hiller, 1999 (The Prison Journal)

35. SufficientRetentionSufficientRetention EarlyEngagementEarlyRecovery Posttreatment DrugUseDrugUse CrimeCrime SocialRelationsSocialRelations ProgramParticipationProgramParticipation TherapeuticRelationshipTherapeuticRelationship BehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange InmateAttributesInmateAttributes Motiv Evidence-Based Treatment Model SupportiveNetworksSupportiveNetworks Inductionneeded? Simpson, 2001 (Addiction) Aftercare Aftercare

36. Problems at Treatment Admission (TCU Self-Ratings at Intake in 1996) N=409; Dees, Pitre, & Dansereau, 1997, Annual Report on 1996 IntakesChanges over time?

37. Hostility and Treatment Dropout Rates (% with high Hostility scores [4+ on 1-7 scale]) N=399; Broome et al., 2000, ACJS Conf Presentation (New Orleans)

38. - - + + Predictors of Early Engagement PersonalInvolvement Psychosocial Functioning at Intake Client Ratings at Month 1 N=399 ; Hiller et al., in progress, 1998 Wilmer admissions Background Characteristics PersonalProgress Trust in Staff AgeAge FemaleFemale Alcohol Prob Coc Prob + SelfEfficacySelfEfficacy AnxietyAnxiety HostilityHostility Desire for Help Desire

39. Multivariate Model of Early Dropout (Stepwise Logistic Regression) BackgroundBackground EarlyDropoutEarlyDropout PsychosocialPsychosocial Odds Ratio=2.6 Odds Ratio=1.5 Odds Ratio=2.1 N=339; Hiller, Knight, & Simpson, 1999 (The Prison Journal) High Risk Low Self-efficacy UnemployedUnemployed

40. Multi-Site Predictors of Recidivism Recidivism Hiller et al., 1999 (Addiction); Wexler et al., 1999 (CJB) Younger Age Previous Arrests ASP/Hostility Childhood Problems MotivationalReadinessMotivationalReadiness Trt Satisfaction AftercareCompletion - Strongest Predictors

41. R.Krupp – CDC-OSAP, in press. 3/03

42. Property * Person Other R.Krupp – CDC-OSAP, in press. 3/03

43. Does In-Custody Therapeutic Community Have Any Impact On Custody Staff? Let’s find out

44. Inmate Rules Violation Reports (115’s) In: Corrections Compendium, 2001, Deitch, Koutsenok et al.

45. Inmate Rules Violation Reports (115’s) In: Corrections Compendium, 2001, Deitch, Koutsenok et al

46. Use/Possession of Controlled 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

47. Sick Related Absenteeism (Sick Calls) In: Corrections Compendium, 2001, Deitch, Koutsenok et al

48. Occupational Injuries (Documented Worker’s Comp) In: Corrections Compendium, 2001, Deitch, Koutsenok et al

49. Effects of Treatment Environment on Custody Staff: Perception of Health In: Corrections Compendium, 2001, Deitch, Koutsenok et al

50. Custody Staff - Perceptions of Job-related Stress (SATF-SAP) In: Corrections Compendium, 2001, Deitch, Koutsenok et al No Stress High Stress

51. 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

52. 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.

53. 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.