3003CCJ Rehabilitating Offenders Week 8: Assessment and Treatment with Substance Dependent Offenders James Byrne, Professor Substance use & Crime Disentangling criminality from illegality Coincidence of substance use and crime Substance use among offenders High rates of alcoholism & problem drinking among offenders High rates of illicit drug use by offenders Offending among substance users
High rates of offending among alcoholics High rates of offending among illicit drug users Substance use & Crime Longitudinal studies Substance use is a strong predictor of later delinquency for 6-11 year olds, but a weak predictor for 12-14 year olds While drinking and crime co-occur in adolescence, little evidence that drinking causes crime
Delinquency often precedes drinking & drug use Alcohol use generally precedes cannabis use; problem drinking may mediate progression from cannabis to hard drug use Substance use & Crime Summary of evidence (consistent findings) Offenders are likely to be heavy drinkers / substance users
2. Heavy drinkers / substance users more likely to be involved in crime 3. Testing of arrestees shows high levels of concurrent drug/alcohol use 4. Substance-using offenders report relationship between substance use and crime 1. Substances, people, and situations Substance variables: Alcohol use associated with violent offending; illicit drug use associated with acquisitive crime
Alcohol + illicit drugs (esp heroin) more likely still to be associated with violent offending Beer and spirits associated more with crime than other alcoholic drinks; opiates & cocaine associated more with crime than other illicit drugs Substances, people, and situations Person variables: Substance users, like offenders, tend to be young males Psychopathic offenders more likely to have alcohol or drug problems Alcohol use/dependence + mental disorder =
higher risk for aggression Substances, people, and situations Situation variables: Violence tends to occur in places where drinking occurs (e.g., pubs & clubs) Closing times are peak risk periods Victims of violence often under the influence of alcohol Places of social drinking may be targeted by
police Places where drugs or alcohol consumed may be places where crime is planned Violence may be associated with drug dealing Common Approaches to Treatment Clinical assessment Patterns of use; method of administration; life problems etc Pharmacological treatments e.g., Antabuse; methadone; naltrexone Detoxification (supported withdrawal)
Motivational interventions (stages of change) Admitting to the problem (e.g., addressing justifications) Common Approaches to Treatment Psychoeducation Cognitive restructuring (e.g., via group- based psychotherapy) Behavioural treatments (e.g., cue exposure; aversive conditioning) Relapse prevention
Identifying behavioural patterns; high risk situations; self-monitoring; coping strategies Abstinence programs (e.g., AA; NA) Abstinence versus controlled use Harm minimisation Engaging substance dependent offenders Trait model of motivation Motivation as a stable, internal characteristic cant change if you dont want to: the concept of
will power hitting rock bottom: the role of confrontation Minimises importance of external influences (esp. therapist behaviour) Treatment failure as moral culpability Licence to be suspicious, hostile, confronting, moralising, & unempathic Engaging substance dependent offenders Client, therapist, & client-therapist relationship factors associated with ve/+ve treatment outcomes
Client characteristics Positive expectations Optimal level of emotional arousal Inertia/lack of effort; feeling overwhelmed Involvement in therapeutic process Shared agenda; collaboration Engaging substance dependent offenders Therapist characteristics associated with +ve outcomes Empathy; warmth; genuineness; congruence;
Therapist-client relationship factors associated with +ve outcomes +ve therapeutic alliance Warm, affectively charged, empathic relationship Active collaboration Engaging substance dependent offenders Motivational Interviewing: Four general principles (Miller & Rollnick) 1. Express Empathy 2. Develop discrepancy 3. Roll with resistance
4. Support self-efficacy Engaging substance dependent offenders Motivational interventions Giving advice Evidence of effectiveness when in sympathetic & constructive terms Providing feedback Status & severity of problem; prognosis with/out treatment; filmed self-confrontation?
Goal setting Needs to be specific & achievable; demanding rather than easy; proximal rather than distal; best in combination with feedback Providing choice Decreases resistance & drop-out; increases compliance; improves effectiveness Engaging substance dependent offenders 6 stages of change (Prochaska et al. 1994)
Pre-contemplation Client does not acknowledge problem Resistance to change Denial & externalising blame (e.g. other peoples fault) Contemplation Acknowledgement of problem Serious thought about dealing with the problem
May last months or years Preparation Prepares to take action May inform significant others Engaging substance dependent offenders Stages of change (contd) Action Client begins to modify patterns of drug use May engage in formal program This stage requires greatest commitment of time and effort
Maintenance Client works toward preventing lapses and relapses Termination Reached when former problem no longer presents a temptation or threat Client is (realistically) confident of coping with problems without relapsing Relapse Prevention
RP developed by Marlatt & Gordon (1985) specifically for use with substance dependence problems Does not seek to cure the problem, but to provide a structured means of control (inc. selfcontrol) and abstinence maintenance Key concepts and principles Relapse Prevention Recovery
Process of initiating and maintaining abstinence Factors associated with problem onset likely to be different from those associated with maintaining pattern of use Often involves personal and lifestyle change Mediated by level of motivation; severity of substance use & related problems; personal factors; & social support Some clients able to achieve & maintain long-term recovery; others experience multiple relapses Key concepts Relapse Prevention
& principles (contd) Lapse An initial episode of substance use following period of recovery May or may not lead to relapse Many clients able to get back on track following a lapse; others move toward relapse Clients response to lapse very important in whether it leads to a relapse (abstinence violation effect) Relapse A breakdown in the clients attempts to modify
substance use Relapses vary in terms of severity of further substance use and its adverse effects Key concepts & principles (contd) Relapse Prevention High risk situations Situations in which the risk of lapse/relapse is increased
Intrapersonal (e.g. ve mood states) Interpersonal (e.g. social pressure to use; relationship conflict) Situational (e.g., availability / opportunity / cues) Lifestyle (e.g. boredom; lack of productive activities) Relapse warning signs Cues, triggers & cravings Lapses & relapses typically preceded by overt & covert warning signs Intervention involves teaching client to identify & develop strategies to anticipate and cope with these
Does it Work? University of Maryland study Effectiveness linked directly with length of time offender remains in treatment Effectiveness unrelated to voluntary/non-voluntary involvement in treatment Prison-based therapeutic community programs effective Especially when linked to community-based follow-up services Increased monitoring/management not effective
Effectiveness of community-based treatment uncertain Weak methodologies in evaluation studies Urine testing may identify drug-using offenders sooner, but weak evidence that it is effective in reducing recidivism Difficulties / Obstacles Complex relationship
between substance use and criminal behaviour Separating criminality from substance use Often need to deal with criminal behaviour separately from substance dependence problems Highlights need for individualised assessment & treatment Prison as artificial environment Many illicit drugs available in prison
Exposure to drug-taking culture Supply vs demand solutions Soft vs hard drug use Difficulties / Obstacles Prison environment (contd) Prescription drugs as a substitute (e.g. benzodiazapines) Unable to observe client (and client unable to observe themselves) in a natural environment Prisoners may be prone to unrealistic goal setting Transition from prison to community
Continuity from prison to community corrections Accessing & co-ordination of community-based services Return to drug-taking environments / The Implementation and Impact of Drug Courts Drug Courts and New Technology of Offender Change The Drug Court Movement Number of Drug Courts :As of December 31, 2007, there are 2,147drug courts in operation, a 32%increase from 2004.
Capacity of Drug Courts: over 70,000 drug court clients are currently being served at any given time throughout the United States and its territories. Graduates:morethan19,900participants graduated from drug court in 2005. Drug Courts: Pre-Conviction vs PostConviction Strategies Old Strategies: the first generation of adult drug court programs, which tended to be diversionary or pre-plea models, New Strategies: Today only 7% of adult drug courts are diversionary programs compared to 59% which are strictly post
conviction. Separating Alcohol-Related Offenses From Other Drugs DWI Offenders: Recognizing that repeat DWI offenders pose a threat to society in a way very different from other offenders, many jurisdictions are establishing a distinct DWI court or a Hybrid DWI/drug court. DWI Courts: Unlike drug courts, however, DWI Courts operate only at the postconviction stage. Drug Court Purpose: Why Do we Need A Specialized Court?
Drug Offenders pose a unique challenge to our court system; they are different than offenders who break other criminal laws. Traditional Court Systems focus on determination of guilt and sanctions, not the addiction problem. Judges need specialized training and courts need specialized services and supervision for drug offenders. How Do Drug Courts Operate? Drug courts represent the coordinated efforts of justice and treatment
professionals to actively intervene and break the cycle of substance abuse, addiction, and crime. Drug Courts are an alternative to less effective interventions, Drug courts quickly identify substance abusing offenders and place them under ongoing judicial monitoring and community supervision, coupled with effective, long-term treatment services. What Happens in a Drug Court? A drug court participant undergoes an intensive regimen of substance abuse
treatment, case management, drug testing, and probation supervision while reporting to regularly scheduled status hearings before a judge with specialized expertise in the drug court model. Drug courts also provide a wide array of ancillary services such as mental health treatment, trauma and family therapy, job skills training, and many other life-skill enhancement services. What is the Drug of Choice for Drug Court Participants? Drug Types Vary by Location
Urban Drug Courts: cocaine/crack is the primary drug of choice for urban drug court clients, Suburban Drug Courts: marijuana is the primary drug of choice for suburban drug court clients, Rural Drug Courts: methamphetamine is the primary drug of choice for rural drug Impact of Drug Courts: Do They Work? OVERALL Impact: According to over a
decade of research, drug courts significantly improve substance abuse treatment outcomes, substantially reduce crime ,and produce greater cost benefits than any other justice strategy Research Findings: Drug Use, And Other Criminal Behavior: Drug Use: This is a difficult question to answer definitively. Criminal Behavior: Four independent metaanalyses have now concluded that drug courts significantly reduce crime rates an average of approximately 7 to 14 percentage points
What is the Cost Effectiveness of Drug Courts? California Researchers concluded that drug courts cost an average of about $3,000 per client, but save an average of $11,000 per client over the long term The Multnomah County Oregon Drug Court was found to cost less than business as usual for drug offenders, because probationers typically have multiple failed treatment experiences that are very expensive but elicit few gains.
Variations on a Theme: Emerging Models DWI Court Family Dependency Treatment Court Gambling Court Reentry Court Federal District Drug Court Juvenile Drug Court Mental Health Court Drug Court Technology and Individual Offender Change Hard Technology Innovations: New Drug testing Devices, New Drug Treatment Strategies involving drug replacement.
Soft Technology: New Classification Systems designed to target offenders amenable to treatment in a drug court setting, new information sharing protocols, and case management systems Tipping Point: What is the Link Between formal and informal social controls? Why Do we use and abuse drugs and alcohol? Why are some drugs legal and others illegal? Can drug users be forced to change using the threat of sanctions and mandatory treatment?
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