The Effectiveness of Substance Abuse Treatment with Young Offenders
- 3.2 In-treatment variables
3. Substance Abuse Treatment for Youthful Offenders: What Works! (cont'd)
Several researchers have highlighted the critical importance of exploring the "black box" of treatment. Process evaluations in which researchers examine program and policy delivery issues that accompany any intervention are the method of choice for achieving this goal (Cullen & Gendreau, 2000; Rossi, Freeman, & Lipsey, 1999; Sealock, Gottfredson, & Gallagher, 1997). By not attending to these process issues, it is virtually impossible to determine whether a treatment program is truly responsible for the observed results and, more importantly, how it actually works (Danegger, Cohen, Hayes, & Holden, 1999, cf. Mears & Kelly, 2002). Despite the beneficial contributions of these types of studies to the correctional treatment literature, this evaluative approach has essentially been ignored in the mainstream criminological literature (Mears, Kelly, & Durden, 2001; Prendergast, Podus, & Chang, 2000). This unfortunate situation is compounded by the fact that most program evaluations examine programmatic impacts on only a short list of outcome variables, such as recidivism, which results in a very limited and arguably incomplete perspective of program success (Harachi, Abbott, Catalano, Haggerty, & Fleming, 1999).
Although outcome evaluations of programs are of paramount importance in ascertaining the effectiveness of a particular intervention, not knowing how the participant performed in the treatment (e.g., was there a decrease in a treatment-related outcome variable such as attitudes favourable to substance abuse), makes it difficult, if not impossible, to directly tie the effects of program participation to the outcome achieved. Linking changes in intermediate measures to program outcome data is the most comprehensive and reliable assessment of correctional program effectiveness (Andrews & Bonta, 1998). As summarized nicely by Prendergast et al. (2000), if programs possessing a certain combination of characteristics are responsible for significant differences in the observed therapeutic impact, then agencies responsible for delivering such programs can improve the effectiveness of their treatment services by focusing on these characteristics. Several variables fall within this broad category of program factors and include program setting, organizational characteristics, program length, program targets, relapse prevention, client-treatment matching, and style and mode of program delivery.
In the broader correctional treatment literature, much has been made of the impact of the program delivery site on client outcome. More specifically, several researchers have argued that programs should ideally be delivered within community as opposed to residential settings (Andrews et al., 1990; Andrews & Bonta, 1998; Hill, Andrews, & Hoge, 1991). This has also been debated in the substance abuse treatment literature, although the terminology is somewhat different with outpatient and inpatient programs corresponding to community and residential programs respectively.
Several studies have explored the impact of inpatient versus outpatient substance treatment programs on client outcome. However, to date, the evidence supporting the differential effectiveness of one over the other is lacking (Annis, 1990; Catalano et al., 1990). More specifically, some evaluations have reported both settings yield equally positive results whereas others have found greater improvements within one at the exclusion of the other. Appropriately interpreting these findings is compounded by the fact that these studies have employed different outcome measures and follow-up periods (Catalano et al., 1990). Furthermore, and arguably more important, the applicability of these findings to substance-abusing young offenders is questionable given the fact that the aforementioned results were generated from the broader adolescent substance abuse treatment literature. Therefore, some of the findings from the broader correctional treatment literature will be reviewed here to supplement this discussion.
Previous meta-analyses of the correctional treatment literature have found significant impacts of program setting on program outcomes for young offenders. More specifically, programs delivered in community settings have achieved significantly higher mean reductions in recidivism than those conducted within an institutional setting (Dowden, 1998; Hill et al., 1991). A more recent meta-analytic review of the substance abuse treatment literature by Dowden, Bania and Andrews (in preparation) provides some additional preliminary evidence. These authors reported that young offender substance abuse programs yielded a more positive client outcomes (as measured by reduced recidivism) when delivered in a community as opposed to residential setting.
Another intuitively appealing variable that may be reasonably assumed to be related to program effectiveness is program length. Although preliminary evidence from both correctional (Sealock et al., 1997) and non-correctional populations (Friedman et al., 1986; Hubbard et al., 1985; Latimer, Newcomb, Winters, & Stinchfield, 2000) suggests that length of treatment is positively related to program completion, its contribution to overall program effectiveness is minimal (Catalano et al., 1990). Despite this discrepancy, a recent study by Latimer et al. (2000) may help explain this state of affairs. More specifically, their results indicated that although length of treatment was positively associated with client outcome for inpatient and outpatient settings, this effect was only evident at six months following program termination. The authors suggested that previous contradictory findings and the limited magnitude of the effects may be explained because the studies did not sufficiently follow-up program graduates to capture the therapeutic impacts of the program. Clearly, replication of these findings in non-correctional and, more importantly for the present review, correctional samples of adolescents is key.
As mentioned, the findings for program length have only been examined explicitly in non-offender adolescent substance abusing populations. In the broader correctional treatment literature, Dowden (1998) reported that program length (measured in treatment hours) was associated with significantly improved client outcomes for young offenders. Thus, further explorations of the impact of program length on client outcome are warranted as the preliminary evidence suggests this is an important programmatic consideration.
Several recent meta-analyses of the broader correctional treatment literature have made a concerted effort to focus more specifically on the programmatic targets of the intervention to observe their impact on client outcome. Although some studies have divided these factors into criminogenic as opposed to non-criminogenic needs (Dowden & Andrews, 1999a, 1999b, 2000; Dowden et al., in press), others have followed a more generic approach (Garrett, 1985; Lipsey, 1995; Lipsey & Wilson, 1998; Pearson & Lipton, 1999). Regardless of the perspective taken, each of these meta-analyses has demonstrated that the types of program targets, including but not limited to substance abuse, have significant effects on program outcome.
Wilson et al., (2001) recently explored the effectiveness of several types of school-based prevention programs on alcohol/drug use through a meta-analytic review of the extant literature. They divided the interventions into two broad categories, environmentally focused (e.g., classroom instructional management, establishing norms or expectations for behaviour) and individually-focused (e.g., self-control or social competency training). Overall, very few of the interventions were sufficiently explored to ensure reliable conclusion, but the most effective type of program was environmentally-focused, although the effect was small (roughly .10).
Although the above meta-analysis exclusively focused on school-based prevention programs, the overall conclusions are relevant to the young offender substance abuse treatment literature as well. Wilson et al. (2001) concluded that it is highly unlikely that any single type of strategy implemented in isolation, will have a large impact on client alcohol or drug abuse, a position well-supported by their data. This suggests that a more meaningful way to explore the question of "what works" is to focus on which combinations or sequences of program types work best. Clearly, past research has essentially ignored issues surrounding the potential additive and multiplicative effects of combining different programs. The importance of the concurrent or sequential delivery of programming is even more evident when considering the co-occurrence of substance abuse with various other forms of problem behaviour. As a result, Wilson et al. (2001) urged researchers to explore the relative effectiveness of different sets and combinations of interventions so that a knowledge base can be developed which will aid in the selection of the most appropriate constellation of programs for a particular treatment population.
The above suggestion has also been forwarded by several other researchers (Annis, 1990; Farrell et al., 1992; Greenwood, 1992). As noted by these authors, since research has generally found that there is a constellation of factors operating concurrently (including substance abuse and delinquent behaviour), from an intervention perspective, this implores program deliverers to ensure that multiple problem areas (e.g., academics, family, antisocial peer group membership) are targeted or else the intervention will not be as effective.
One potential avenue of investigation for enhancing program effectiveness is involving the family in the treatment program. More specifically, Dobkin et al. (1998) found that treatment completion was far better in cases where the parents were actively involved in the program than when parents were not. Further confirmatory evidence for the importance of familial variables was found in a recent program evaluation of a substance abuse program offered to youthful offenders as program staff identified family issues as one of the key barriers to successful program completion (Mears et al., 2001). Finally, several researchers have lauded the utility of involving other family members in preventative efforts aimed at keeping adolescents from developing substance abuse problems (DeMarsh & Kumpfer, 1985; Kumpfer & Turner, 1990).
The importance of family treatment for young offenders has also been demonstrated in various meta-analyses of the correctional treatment literature (Dowden & Andrews, 1999a; Garrett, 1985; Latimer, 2001; Lipsey, 1995). However, Dowden and Andrews (1999a) noted that not necessarily all forms of family intervention are effective. More specifically, programs that focused on increasing family affection and monitoring/supervision practices yielded significant mean reductions in re-offending compared to control groups. More generic family intervention programs (e.g., those that did not discuss their family-oriented treatment targets), however, were associated with negative client outcomes. Thus program administrators should ensure that they are explicit regarding their program targets and address familial factors important for reducing criminal behaviour in adolescents.
Although it could be argued that relapse prevention should be considered a program target, given its popularity within the substance abuse treatment literature and the more recent expansion of this concept into a complete programmatic framework, it was decided to address this topic separately. The necessity of incorporating some form of relapse prevention into a substance abuse treatment program is illustrated in previous work where relapse rates have been reported as high as 85% in both adult and adolescent substance abusers (Catalano et al., 1990). Thus, it is not surprising that the relapse prevention approach has been viewed as an integral component of delivering effective treatment (Annis, 1990; Catalano et al., 1990).
The relapse prevention model was originally developed to aid in the treatment of various addictive behaviours such as substance abuse, cigarette smoking and overeating (Marlatt & Gordon, 1985). Its primary goal was to buffer the positive behavioural changes achieved by participating in a particular treatment program through the enhancement of various self-management strategies (Bakker, Ward, Cryer, & Hudson, 1997). More specifically, it focused on teaching an individual how to identify particular high-risk situations, introduce coping styles as well as enhance feelings of self-efficacy in dealing with these situations (Bakker et al., 1997; Laws, 1999; Marlatt & Gordon, 1985).
The strong intuitive appeal of the relapse prevention model, coupled with its focus on treating various other addictive behaviours, has resulted in the model being applied to the treatment of substance-abusing (Peters, 1993) and sexual offenders (Laws, 1999; Pithers, Marques, Gibat, & Marlatt, 1983; Ward & Hudson, 1996). Other researchers have stressed that relapse prevention should also be applied within the treatment of general offender populations wherever possible (Cullen & Gendreau, 1989; Gendreau, 1996).
Despite the widespread coverage given to this approach within the mainstream literature, few controlled outcome studies have formally evaluated its effectiveness within both correctional (Laws, 1999) and non-correctional samples (Catalano et al., 1990; Stephens, Roffman, & Simpson, 1994). However, a recent meta-analysis of the correctional treatment literature by Dowden et al. (in press) consolidated the findings of correctional interventions that targeted relapse prevention as one of their program targets. The authors found relapse prevention programs as a whole to be effective, resulting in an average 15% decrease in recidivism for treatment versus comparison group subjects. More importantly for the present review, it was found that using relapse prevention with youthful offenders yielded significantly stronger programmatic effects in terms of recidivism reduction than when it was used with adult offenders. Thus, the critical importance of incorporating elements of relapse prevention in a treatment protocol for young offenders seems evident based on the above-reviewed findings.
Several researchers have noted that one of the most critical aspects of effective programming involves appropriate client identification, assessment and referral (Farabee et al., 1999; Hiller et al., 1999a). A technique adopted in the substance abuse treatment field to deal with this concern has been labelled client-treatment matching, otherwise known as the matching hypothesis (Annis, 1990). The fundamental principle underlying this approach is that a client with a certain set of factors may respond more favourably to a particular kind of treatment program or setting than another, and that due diligence must be exercised to ensure appropriate matching of client to treatment is achieved to maximize the therapeutic benefits of program participation. Despite the relative recency of the concept, Annis (1990) found empirical support for this hypothesis in her review of the substance abuse treatment literature as she reported 15 studies had documented positive programmatic effects as a result of this practice.
Client-treatment matching has also received support in the broader correctional literature. More specifically, the recent meta-analytic review conducted by Dowden (1998) reported that programs that assessed the needs of the offender at intake and subsequently assigned him/her to an appropriate treatment program based on this assessment, yielded significantly higher mean reductions in re-offending compared to programs that did not employ this practice. This trend has also been found in correctional program evaluations that involved juvenile (Dowden & Andrews, 1999a) and female offenders (Dowden & Andrews, 1999b).
Overall, these studies provide convincing empirical evidence for the clinical utility of this approach when delivering correctional treatment to substance abusing young offenders. This practice has a great deal of intuitive appeal, as one would expect that individuals assigned to programs that target an identified "personal" need area would be much more likely to obtain more positive effects from program participation.
Considerable research attention has focused on the style and mode of program delivery, with particular emphasis being placed on determining whether cognitive-behavioural/behavioural (such as modeling, graduated practice, rehearsal, and role playing), or non-behavioural methods which follow a more didactic approach, are equally effective when delivering substance abuse treatment to adolescent populations. The vast majority of the evidence to date suggests that cognitive-behavioural/behavioural methods are far superior and this fact has been demonstrated within school-based substance abuse programs (Wilson et al., 2001), broad correctional samples (Dowden, 1998; Dowden & Andrews, 1999b; Losel, 1995), young offenders (Dowden, 1999a; Lipsey, 1995) and substance abusing offenders (Pearson & Lipton, 1999). Clearly, this plethora of research evidence supports a behavioural or cognitive-behavioural framework for delivering substance abuse treatment to youthful offenders.
Recently, correctional investigators have begun to explore the role of organizational-level variables (e.g., staff turnover, staff training, organizational support for rehabilitative ideal) in the delivery of effective correctional treatment. This shift in focushas been motivated by the fact that substantial variations in program effectiveness have been documented within programs, even those following the same treatment modality (Prendergast et al., 2000). Although very little research to date has focused on these issues, the preliminary empirical evidence suggests that organizational factors may be the most important determinants for successful programs due to their strong influence on program implementation and delivery (Cullen & Gendreau, 2000; Farabee, Prendergast, Cartier, Wexler, Knight, & Anglin, 1999; McBride, VanderWaal, Terry, & VanBuren, H., 1999; Mears et al., 2001).
One such organizational variable that may impact the therapeutic potential of the program is staff turnover (Farebee et al., 1999; Mears & Kelly, 2002). Several intuitively appealing explanations for the link between increased staff turnover and poorer program performance have been forwarded by Mears and Kelly (2002). First, the youths may be attached to those officers who leave their positions and subsequently the youths feel abandoned and may not put as much effort into the program. Furthermore, hiring new staff who require extensive training may impinge on the effectiveness of the program as these new employees will not be as effective with program clients. Finally, as has been noted by several other correctional investigators, the difficulty in maintaining and nurturing a therapeutic milieu for program clients with constant turnover of staff is a colossal task as replacement staff members have limited knowledge of the program and its participants (Farabee et al., 1999; Harachi et al., 1999).
Another organizational variable that has received preliminary support in the extant literature is the age of the program. For example, Mears and Kelly (2002) found that newer programs evidenced stronger programmatic effects, presumably because of the enthusiasm and sustainable human and fiscal resources surrounding the venture. This finding has also been found in the broader correctional treatment literature (Dowden, 1998). Thus, attention should be given to ensure more seasoned programs maintain both their enthusiasm and funding so they continue to have a positive impact for program clients in the later stages of their existence.
Although preliminary, several individual studies have found additional setting or organizational variables related to client outcome in substance abuse treatment programs. McCaughrin and Price (1992) reported that clients performed significantly better in programs that had a larger number of treatment staff, were "for-profit", made sobriety a condition of treatment involvement, provided post-treatment referrals, and conducted post-treatment follow-up assessments of clients. Magura and colleagues (1999), in a large-scale review of methadone maintenance programs, found that the experience of the clinic director and his/her direct involvement in delivering treatment services to the clients, as well as number of counselling contacts, were positively related to program outcome. A recent meta-analytic review of drug dependence treatment programs (Prendergast et al., 2000) found that within a given modality, enhanced client outcomes (as measured by decreased drug use and criminal
activity) were observed in programs
“ that closely monitor the integrity of the treatment protocol, that have a lower ratio of counsellors to clients, that have higher retention rates, and that offer more hours of contact time ” (p.1958). Finally, Farabee et al. (1999) noted that recruitment and training of treatment staff, leadership, capacity, and more generally, support for rehabilitation were important organizational level variables that could affect program outcome. Mears and Kelly (2002) also found confirmatory evidence for the latter point within a substance abuse program for young offenders.
A recent meta-analysis of the correctional treatment literature provides strong empirical evidence for the clinical utility of a cluster of organizational-level variables termed program integrity (Andrews & Dowden, under review). Program integrity refers to a program that is conducted in practice as intended in theory and design (Hollin, 1995). In the Andrews and Dowden (under review) meta-analysis, programs were evaluated on their adherence to program integrity based on whether the program followed a specific model, whether the staff were appropriately selected, trained and appropriately supervised, whether printed materials (e.g., program goals and content) were available, and whether monitoring of changes on intermediate outcome measures was conducted. The results indicated that each of these aspects of program integrity were associated with enhanced program effectiveness. More importantly, all of these indicators, with the exception of monitoring in-program changes, were linked with significant programmatic improvements in terms of client outcome (e.g., programs that incorporated these elements of program integrity yielded significantly higher mean reductions in re-offending than programs that did not use these elements).
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