Elements of an Effective Substance Abuse Treatment Model for Offenders

1

• Elements of an Effective Substance Abuse
  Treatment Model for Offenders
• Correctional Service of Canadas Model

2
Overview

• Research-based Offender Treatment
• Part I Effective Intervention
• Substance use and abuse
• Components of Effective Substance Abuse
  Interventions
• Part III Effective Programming
• Components of Effective Substance Abuse Programs
• Overview of CSCs Substance Abuse Programs
• Part IV Maintenance and Aftercare
• Principles of Relapse Prevention
• Factors to consider
• Part VI Service Quality and Monitoring
• Program Management

3
Research Based Offender Treatment (Part I)

• Effective Intervention
• Substance Abuse Stages of Acquisition
  Intervention
• Models and implications for treatment
• Principles of Effective Intervention
• Best practices in intervention

4
Substance AbuseStages of Acquisition
Intervention
Initial Abstinence
First Experimentation
Non-problematic Substance Use
Substance Use
Substance Dependence
Treatment
Primary Prevention
Secondary Prevention
5
Models and Implications for Treatment

• The way substance abuse is understood influences
  the mode of intervention, e.g., Brickmans Model

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Substance AbuseBrickmans Model
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Models and Implications for Treatment

• Selection of an over-arching approach to
  intervention based on
• Principles of effective correctional intervention
• Best practices literature

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Principles of Effective Correctional Programs

• Andrews (2000) Principles
• Intervention based on a psychological theory of
  criminal behaviour that includes a general
  personality and social learning approach
• Introduce human service strategies do not rely
  on principles of retribution, restorative
  justice, deterrence or incarceration
• Community-based services are preferred
• Match intensity of intervention to level of risk

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Principles of Effective Correctional Programs

• Target known criminogenic need multimodal is
  best, i.e., multi-need
• Assessment of risk and need must be based on
  reliable and valid tools
• Address responsivity and strength factors
• Must include aftercare
• Develop individualized plans
• Integrity of program implementation and delivery
• Attend to staff, managers and the broader social
  context

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Summary of Best Practices

• Treatment with support
• Pharmacological intervention has a role with
  conditions and requires treatment
• Behavioural relapse prevention programs
• Community reinforcement
• Martial therapy
• Social skills training
• Stress management
• Health Canada (1999) Best Practices Substance
  Abuse treatment and rehabilitation

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Best Practices Summary

• Effective Treatment Factors
• Programming matching is needed
• Treatment should be in a group format unless
  contraindicated
• Outpatient treatment is cost-effective
• Brief interventions only with stable individuals
  with low to moderate problems
• Treatment effect enhanced by competent service
  providers

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Best Practices Summary

• Intervention with Specialized Groups
• Some evidence for the efficacy of mandated
  treatment
• Insufficient evidence to support provision of
  specific types of interventions to women
• Adolescents need flexible approaches
• Seniors benefit from community-based treatments
• Integrate services for dually diagnosed
  individuals

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Effective Intervention

• Operationalising what works
• Substance use falls along a continuum
• The intensity of the intervention matches
  severity of problem
• Create and mobilize community-based resources for
  primary and secondary interventions
• Cognitive-behavioural models integrating relapse
  prevention are effective models of treatment
• Provide group interventions
• Include harm reduction strategies
• Ensure integrity in program delivery and
  management

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Research-based Intervention for Offenders Part
III

• Elements of Effective Programming
• Empirically supported model
• Effective methods for intervention
• Multimodal approach to intervention
• CSCs Substance Abuse Programs

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Empirically Supported Model

• Cognitive-Behavioural Model
• Addictive behaviours are as a result of the
  interaction between biological, psychological and
  sociocultural factors
• Addictive behaviours are maladaptive because they
  are the central or sole means to feel pleasure
  and to deal with lifes demands
• Changing behaviour and thinking will modify
  existing patterns
• Relapse Prevention
• Most people dont successfully change behaviour
  on first effort
• Individuals identify their risk factors and
  broaden ways to cope in order to decrease
  likelihood of lapsing or relapsing into old
  patterns

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Effective Methods

• The intervention is most effective when it is
• Structured
• Has built in reinforcement, modelling and skills
  acquisition through role-plays, graduated
  approximations and extinction
• Responsivity factors are identified and addressed

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Effective Methods

• Same processes that maintain substance abusing
  behaviours are used in treatment to change
  patterns (Reinforcement, modelling , skill
  acquisition through role-play and graduated
  approximations, cognitive restructuring)
• Motivational enhancement strategies
• Harm reduction model

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Multi-modal Interventions

• Assertion training
• Social skills training
• Problem solving
• Controlled drinking strategies
• Methadone maintenance
• Employment training

• Recognition of high risk situations
• Relapse prevention
• Behavioural self-control
• Stress management
• Marital
• Aftercare

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CSCs Integrated Model of Change

• Psychology of Criminal Conduct (Andrews Bonta)
• Social Cognitive Theory (Bandura)
• Cognitive Behavioural
• Relapse Prevention Therapy (Parks Marlatt)
• Coping Model of Criminal Recidivism (Zamble
  Quinsey)
• Transtheoretical Model of Change

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Integrated Model

• Crime because learning and skills deficits
• Substance abuse because of learning, dependency
  and deficits
• Behr is maintained by past learning, including
  peer modeling, reinforcement contingencies,
  cognitive expectations, and biological influences
• Substance abuse and crime linked
• Change patterns of substance abuse to decrease
  relapse and recidivism
• Motivational enhancement necessary to facilitate
  change

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CSCs National Substance Abuse Programs (NSAP)

• There are three levels of program intensity to
  address differing severity of problem high,
  moderate and low
• Programming starts at the beginning of the
  sentence, where warranted
• Aftercare is mandatory

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Program Timing
Assessed Level of Need Institution Community
High
Moderate
Low
M A I N T E N A N C E
Pre- Release Booster
M A I N T E N A N C E
NSAP High
NSAP Mod
NSAP low
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Menu of Programs
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CSCs application of Effective Program Methods

• Programs are structured with a scripted manual
  for facilitators to follow
• Programs based on the principles of adult
  learning
• Offenders guided to see personal relevance of the
  content
• All skills are introduced, modelled and
  reinforced and frequently practiced
• Facilitators sensitised to responsivity factors
  and given guidance to address

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Skills in CSCs Programs

• Self-control training self-monitoring,
  goal setting,
• Identification of high risk situations
• Problem solving to deal with triggers
• Relapse prevention strategies to manage triggers
• Cognitive coping ABC model to identify risky
  thinking and beliefs, to counter outcome
  expectancies inoculation to come up with
  positive coping thoughts
• Behavioural coping
• Craving management
• Intrapersonal control time out, counting down,
  breathing techniques
• Social skills listening, receiving feedback,
  assertion, negotiation, dealing with pressure,
  asking for help, expressing negative feelings,
  conflict management, empathy building,
  perspective taking and community building

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Where it fits
Self Monitoring Assessment
Efficacy Enhancing Imagery Emotional Regulation
Limit use Slip Management
Decreased Self Efficacy POE
Violation Effect
High Risk Situation
Ineffective Coping
LAPSE
Competency Assessment Skills
Training Relapse Prevention Rehearsal
Decision Matrix Lt vs ST Effects
Analysis of Relapses
Emergency Relapse Plan
Cognitive Restructuring
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Program Phases

• All NSAP intensities have same phases
• Phase I Deciding What I would Like to Change
• Phase II Improving the Odds
• Phase III Learning the tools for Change
• Phase IV Using the Skills and Planning for my
  Future

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Phase I

• Goal is to illustrate how participants became
  dependent upon substances, how it is connected
  with their criminal behaviour and the
  consequences of this across all life domains
• Personal goal setting
• Identification of obstacles and self-management
  deficiencies
• Self-monitoring
• POE related to crime and drugs
• basic social and intrapersonal skills
• Coping with cravings and urges

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Phase II

• Goal is to have participants recognise their
  internal and external risk factors
• Use Inventory of Drug/Drinking Situations to
  identify HRS
• Marlatts model of Relapse Prevention
• How triggers effect them (T-D-G) and how they
  build (G-Y-R)
• Development of integrated crime and substance
  abuse cycles
• Problem solving steps to disrupt the cycles

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Phase III

• Learning Coping by Thinking and Coping by Doing
  skills to create a different life (4 key life
  areas)
• Using Cognitive and Behavioural Coping to develop
• Better relationships intimate partners, friends,
  others authority
• Feeling good enhancing sense of self, emotion
  management, mental health
• Personal control and freedom putting in place
  things to stop the return to substance misuse
• Satisfying life

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Phase IV

• Goal is to finalize the recidivism and relapse
  prevention plans
• Development of life area plans for substance
  use, work/school/finance, relationships, leisure,
  legal, health and well-being, and community
  building
• Evaluate RP and life area plans
• Set goals for continued change and monitoring

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Research Based Offender Treatment Part IV

• Maintenance and Aftercare
• Why Maintenance

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Maintenance

• Research supports that aftercare maximizes
  effectiveness
• Maintenance reinforces and strengthens progress
  made in treatment reflects the principles of
  relapse prevention

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Maintenance

• Factors to consider
• Frequency of contact based on stability and
  functioning external monitoring function
• Relevant for current life circumstances
• Evaluation and enhancement of skill set

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Maintenance

• CSCs aftercare for offenders with substance
  abuse problems
• Institutional Substance Abuse Maintenance Program
• Pre-Release Boosters
• Community Substance Abuse Maintenance Program
• Community Maintenance Program

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Research-based Offender Treatment Part VI

• Service Quality and Monitoring
• Program Management
• Considerations for successful implementation
• Staff Training and Quality Assurance
• Research and Evaluation
• Accreditation of Programs

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Program Management

• Considerations for successful program
  implementation
• Sincere motivation
• Support at the top
• Staff competence
• Cost-benefit surplus
• Clarity of goals and procedures
• Clear lines of authority
• Implementation evaluation
• Program evaluation framework

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Program Management

• What to evaluate
• Direction. Requires strategic planning, mission
  statement with corresponding policy, clear goals
  and objectives
• Existing conditions
• Application of the principles of matching
• Implementation of appropriate intervention
• Therapeutic integrity
• Evaluation of staff

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Program Management

• Staff Training and Quality Assurance
• Staff selection is critical
• Well trained, supervised and supported staff are
  necessary
• CSCs infrastructure includes National, Regional,
  and local management
• Program manual and staff training manual for
  consistency
• Program deliverers are monitored for compliance
  and efficacy, when warranted they are certified,
  and have ongoing follow-up

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Program Management

• Research and Evaluation
• Program evaluation is necessary to assess
  efficacy, cost-effectiveness and inform ongoing
  program development
• Evaluation commenced immediately upon
  implementation

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Outcome Data

• CSCs original programs
• Offenders who completed high intensity program
  demonstrated a 19 reduction in readmission and a
  50 reduction in new convictions
• High intensity program participants were less
  likely to be readmitted (37 vs. 45) to custody
  and were slightly less likely to have their
  conditional release revoked as a result of a new
  offence (4 vs. 8).

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Outcome data

• Offenders completed the moderate intensity
  intervention and showed a 14 reduction in
  re-admission (from 49 to 42) and 31 reduction
  in new convictions (from 21.9 to 15.2)
• Offenders, who completed the low intensity, plus
  maintenance, had a 29 reduction in readmission.
• There was a 56 reduction in re-convictions for
  those who completed maintenance.

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Program Management

• Unit costs for high, moderate, low and
  maintenance intervention
• High - 6,758
• Moderate 1,100
• Low 900
• Maintenance - 364
• Unit costs of in-patient treatment
• 12, 079
• Preliminary data support cost effectiveness of
  intervention

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Program Management

• Accreditation of Programs
• International panel reviews to ensure that new
  programs meet highest standards
• NSAP accredited in December 2003
• 8 criteria explicit, empirically-based model of
  change, targets criminogenic needs, uses
  effective methods, is skills oriented, addresses
  responsivity factors, intensity related to
  severity of problem, offers continuity of care,
  and has ongoing monitoring and evaluation
• After initial accreditation, programs are on a 5
  year cycle