Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality &...

Igor Koutsenok, MD, MSAssistant Professor of Psychiatry, UCSD,

Director,Center for Criminality & Addiction Research, Training & Application

(CCARTA)

Treatment of Substance Treatment of Substance Involved Offenders in Criminal Involved Offenders in Criminal

Justice Settings –Justice Settings –Challenges & OutcomesChallenges & Outcomes

Let’s start with some bad Let’s start with some bad newsnews

California StatisticsCalifornia Statistics

172,785 in prison (1986: 39,373)172,785 in prison (1986: 39,373) Cost – $38 000 per inmateCost – $38 000 per inmate 117,136 on parole (1986: 19,780)117,136 on parole (1986: 19,780) Cost - $12 000 per paroleeCost - $12 000 per parolee 77% of males and 83% of females 77% of males and 83% of females

incarcerated in California have drug incarcerated in California have drug and alcohol problems.and alcohol problems.

Nationwide costNationwide costColumbia University Report, March Columbia University Report, March

20052005

$ 30 billion states spent on adult $ 30 billion states spent on adult corrections (incarceration, corrections (incarceration, probation, parole)probation, parole)

$24.1 billion of it was on substance $24.1 billion of it was on substance involved offendersinvolved offenders

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…On Women…

“What Works,” Dr. Rudy J. Cypser, CURE-NY, 2000

Some Other Sad FactsSome Other Sad Facts Over 2 million inmates inhabited U.S. Over 2 million inmates inhabited U.S.

jails & prisonsjails & prisons They are parents of 3.4 million childrenThey are parents of 3.4 million children 2 in 3 convicts have been tested 2 in 3 convicts have been tested

positive for drugs at time of arrest.positive for drugs at time of arrest. 2 in 3 inmates have verified drug 2 in 3 inmates have verified drug

histories, histories, BUT…BUT…

Under 15 % receive systematic Under 15 % receive systematic treatmenttreatment

Deitch, Koutsenok & Ruiz, 2004Deitch, Koutsenok & Ruiz, 2004

Recidivism Recidivism Within 12 months after release from Within 12 months after release from

custody 70- 75% of substance involved custody 70- 75% of substance involved offenders are back to institutionsoffenders are back to institutions

It is clear that criminal-justice It is clear that criminal-justice sanctions by themselves do not reduce sanctions by themselves do not reduce recidivism in this populationrecidivism in this population

Prisons do manage behaviors, but do Prisons do manage behaviors, but do not shape behaviorsnot shape behaviors

Policies for Drug OffendersPolicies for Drug Offenders

Diversion Incarceration

Probation w/o verdict(Prop 36)

Drug Courts

Intermediatesanctions




Drug Courts


Public Safety

Public Safety RisksRisks




Drug Courts


$$$$$$ Costs $$$$$$$$

$$$$$$ Costs $$$$$$$$

$$

Public Safety Risks

Public Safety Risks




Drug Courts


Over-Over-reliancereliance

PrisonPrison

Criminal Recidivism in 3 YearsCriminal Recidivism in 3 Years 68% re-arrested68% re-arrested 47% convicted47% convicted 50% re-incarcerated50% re-incarcerated

Relapse to Drug Use in 3 YearsRelapse to Drug Use in 3 Years 95% relapse95% relapse

Marlow D., Treatment Research Institute, 2006




Drug Courts





Drug Courts


Over-Over-reliancereliance

Referral to TreatmentReferral to Treatment

50% - 67% don’t show for intake50% - 67% don’t show for intake 40% - 80% drop out in 3 months40% - 80% drop out in 3 months 90% drop out in 12 months90% drop out in 12 months 70% of probationers and parolees 70% of probationers and parolees

drop out within 2 - 6 monthsdrop out within 2 - 6 months

Attrition

D. Marlow D. & T.McLellan, TRI, 2004

Time for some better Time for some better newsnews

What will happen if we

What will happen if we

combine incarceration

combine incarceration

and treatment?

and treatment?

From the work of From the work of Douglas B. Marlowe, J.D., Ph.D.Douglas B. Marlowe, J.D., Ph.D.

Types of Substance Types of Substance Involved OffendersInvolved Offenders

Criminogenic Criminogenic RisksRisks Age during rehabilitation < 25 yearsAge during rehabilitation < 25 years Criminal onset < 16 yearsCriminal onset < 16 years Prior rehabilitation failuresPrior rehabilitation failures History of violenceHistory of violence Antisocial Personality DisorderAntisocial Personality Disorder Psychopathy Psychopathy Familial history of crimeFamilial history of crime Criminal associationsCriminal associations

Criminogenic Criminogenic NeedsNeeds

Drug Dependence or AddictionDrug Dependence or Addiction


Drug Dependence or AddictionDrug Dependence or Addiction1.1. Binge patternBinge pattern2.2. Cravings or compulsionsCravings or compulsions3.3. Withdrawal symptomsWithdrawal symptoms



} Abstinence is a distal goal



Drug Abuse or MisuseDrug Abuse or Misuse






Abstinence is a proximal goal}




Collateral needsCollateral needs– E.g., dual diagnosis, HIV+E.g., dual diagnosis, HIV+


Abstinence is a proximal goal}

High RiskHigh Risk Low RiskLow Risk

High High NeedsNeeds

Low Low NeedsNeeds

Risk & Needs MatrixRisk & Needs Matrix




Low Low NeedsNeeds

AccountabilityAccountability&&

TreatmentTreatment




Low Low NeedsNeeds


TreatmentTreatment

TreatmentTreatment




Low Low NeedsNeeds


TreatmentTreatment

TreatmentTreatment

AccountabilityAccountability




Low Low NeedsNeeds


TreatmentTreatment

TreatmentTreatment

PreventionPrevention

AccountabilityAccountability

Practice ImplicationsPractice Implications



Low Low NeedsNeeds

Frequent meetings Frequent meetings

with PAwith PA Intensive treatmentIntensive treatment ComplianceCompliance is proximal is proximal Positive reinforcementPositive reinforcement

Intensive treatment Intensive treatment TreatmentTreatment is proximal is proximal Positive reinforcementPositive reinforcement

AbstinenceAbstinence is proximal is proximal Restrictive sanctionsRestrictive sanctions

Secondary prevention Secondary prevention AbstinenceAbstinence is proximal is proximal

The profile of a successful The profile of a successful high risk/high need client in high risk/high need client in

community based community based therapeutic community is therapeutic community is

very similar to the one of a very similar to the one of a substance abusing offender substance abusing offender

in custodyin custody

Why Therapeutic Community Model?

Delaware/Crest Program: Delaware/Crest Program: 3-Year Re-Arrest & Drug Use Rates3-Year Re-Arrest & Drug Use Rates

71

95

72

83

51

73

29

41

No Treatment

(n=210)

ITC Dropout*(n=109)

ITC, but noAftercare*

(n=101)

ITC +Aftercare*

(n=69)

% with New Arrests% with Drug Use

Martin, Butzin, Saum, & Inciardi, 2001 (The Prison Journal)

*p<.05

Texas In-prison TC ProgramTexas In-prison TC Program::Return to custody rates (24 months follow-up), 2001Return to custody rates (24 months follow-up), 2001

64

51

2319

33

22

16

3338

45

12

22

27

5

18

0

10

20

30

40

50

60

70

Intake 3 6 9 12 18 24

Months After Discharge

Untreated Comparisons (n=103)Aftercare Non-completers (n=123)Aftercare Completers (n=170)

AftercareCompleters

K. Knight, D. Simpson. The Prison Journal, 2002

California/Amity Program: California/Amity Program: 3-Year Return-to-Custody Rates (%)3-Year Return-to-Custody Rates (%)

7582 79

28

No Treatment

(n=189)

ITC Dropout(n=73)

ITC, but noAftercare(n=154)

ITC +Aftercare*

(n=162)

Wexler, Melnick, Lowe, & Peters, 2002 (The Prison Journal)

*p<.001

Coercion in the CriminalCoercion in the Criminal Justice System Justice System

A 2000 report from the Institute A 2000 report from the Institute of Medicine summarized that of Medicine summarized that

“contrary to earlier fears among “contrary to earlier fears among clinicians, criminal justice clinicians, criminal justice

pressure does not threaten pressure does not threaten treatment effectiveness, and it treatment effectiveness, and it

improves outcomes”improves outcomes”

Research FindingsResearch FindingsMultiple studiesMultiple 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

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 offenders4. Boot camps & periodic drug-focused counseling

have poor outcomes5. Risk assessments should guide selections for Risk assessments should guide selections for

treatmenttreatment

Thank youThank you

Igor Koutsenok, MD, MS Assistant Professor of Psychiatry, UCSD, Director, Center for Criminality &...

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