a behavioral approach to substance abuse prevention in the correctional setting: a preliminary...

A BEHAVIORAL APPROACH TO SUBSTANCE

TIONAL SETTING: A PRELIMINARY REPORT ABUSE PREVENTION IN THE CORREC-

SHERMAN YEN Applied Research and Management, Inc.,

Owings Mills, Maryland 21 I 1 7 MARK PEYROT

CLAUDIA T. PRINO Center for Social and Community Research, Loyola College,

Baltimore, Maryland 2121 0-2699

This study evaluated the effectiveness of a substance abuse program in a correctional institution using social skills training for secondary prevention. Forty-four male inmates with a history of substance use partici- pated in the pilot program. Program topics included drug, alcohol, and substance abuse treatment knowledge and development of anger and stress management skills. A pretest-posttest analysis revealed significant improvement in overall knowledge of program topics and within specific areas. Areas of greatest improvement were drugs and alcohol. Clients and group leaders reported that the program was effective in facilitating attitude and behavior change regarding substance abuse. Results suggest a social competence approach to substance abuse rehabilitation in correctional institutions holds promise for both increasing knowledge and teaching effective skills to resist future substance abuse.

Substance abuse is now viewed as multiply determined, re- sulting from a complex interplay of factors (Donovan & Chaney, 1985). Social, personality, cognitive, attitudinal, and behavioral factors interact to contribute to substance use (Jessor & Jessor, 1977). A variety of social skill deficits have been identified as pro-

Behavioral Residential Treatment, Vol. 4, No. 1 (1989) 0 1989 John Wiley & Sons, Inc. CCC 0884-55 8 1 /89/010053-12$04.00

54/YEN, PEYROT, AND PRINO

moting and/or facilitating initial and recurrent drug/alcohol behavior. Several social skill deficits responsible for initial use include social anxiety, nonassertiveness, low self-esteem, and inadequate social and coping skills (Catalano & Hawkins, 1985; Miller & Eisler, 1977). Recurrent substance use often involves inadequate coping responses to interpersonal stress, social pressure, or negative emotional states such as fear, depression, or anxiety (Marlatt & Gordon, 1980). An individual may begin ex- perimenting with drugs andfor alcohol to cope with and relieve anxiety induced by social situations or achieve popularity. Other individuals may begin using drugs/alcohol as a result of social influences. These individuals do not have the social skills to resist peer pressures, Interpersonal dispositions may also increase suscep- tibility to initial use. Individuals with low self-esteem and self- confidence are more likely to succumb to substance use as a way of increasing self-esteem.

Substance related knowledge per se is not effective in substance abuse prevention and rehabilitation. Outcome evaluations of educational programs indicate increased knowledge has virtu- ally no impact on drug use (Botvin, 1983). Abusers need not only to understand the negative effects of drugs and alcohol but also acquire skills like anger and stress management that will help them cope with stressors related to use. Because of its comprehensive nature, social skills training has become a recommended strategy in the treatment of drug and alcohol addiction (Ballack & Hersen, 1979; Marlatt & Gordon, 1985). Social skills training supplements drug and alcohol education with techniques to handle stressors related to use. A social skills approach to substance abuse intervention enhances personal competence and teaches users problem- specific skills and knowledge that will increase their ability to resist prosubstance-use social pressure.

This broad spectrum treatment approach has been applied in many settings, including inpatient units (Chaney, O’Leary & Marlatt, 1978; Rist & Watzel, 1983), residential drug treatment centers (Hawkins, Catalano & Wells, 1986), and schools (Pentz, 1982). The application of skills training in correctional institutions however, is relatively unexplored. Given the concentration of substance abusers within the inmate population and the role of substance abuse in recidivism, further exploration of social skills training in correctional institutions is warranted.

The aim of the present study was to develop a comprehensive social competence program for use in correctional settings and design an evaluation procedure to determine its effectiveness. The

DRUG PREVENTION IN CORRECTIONS/55

program was designed to provide knowledge about the negative consequences and physiological effects of substance use and teach stress and anger management skills.

PROGRAM DESCRIPTION

The criteria for admission to the program included: (1) docu- mented or self-reported substance use, and (2) high motivation, preferably voluntary admission. Since motivation was instrumental to program success, favorable consideration for early parole was offered as an incentive.

Clients attended 8 group sessions of 90 minute duration held semiweekly, for a total of 12 hours of program participation. Clients were randomly assigned to one of three group leaders. Each group consisted of 8-1 2 participants.

All sessions began with a 30 minute lecture of basic information followed by a 60 minute group discussion. Three group leaders were responsible for delivering the lecture and facilitating group discussion. All group leaders had course work in substance abuse and attended a training session prior to participating in the program. Sessions were conducted according to a protocol designed specifically for the program by one of the authors (Yen). Sessions topics included: (1) pharmacological effects of drugs, (2) pharmacological effects of alcohol, (3) stress management, (4) anger management, and ( 5 ) drug treatment services and options. Sessions were presented in a prespecified order, as delineated in a protocol for group leaders’ use. To facilitate the transfer of information outside the group sessions, homework was routinely assigned to clients. The content of each assignment reflected the discussion topics given that week.

Client participation, crucial to program effectiveness, was evaluated by both client and group leader ratings. Group leaders rated various aspects of client participation and clients rated group leader knowledge, helpfulness, and skills. This information can be used to refine and modify future program delivery.

METHOD

Subjects

Subjects were 44 male inmates of the Baltimore City Jail in Baltimore, MD. Clients were similar to the nationwide incarcerated


Table I. Client Characteristics.

Age 16 to 20 years 21 to 29 years Over 30 years

Education Junior High School Some High School High School Graduate

Marital Status Single Married or Cohabi-

tating

Demographics

Race 43% White 3 2% Black 25% Other Socioeconomic Status

Employment 3 2% Unemployed 34% Part -time 34% Full-time

Family Children

66% Living with Children

34% Children Not Living with

Criminality

57% 36%

7%

24% 3 9% 37%

18%

82%

Current Offense Violent Crime Other

Prior Offenses 42% None 58% One or more

3 2% 68%

population in terms of demographic characteristics (see Table I). Subjects ranged in age from 16 to 57, with a mean age of 26.8* 10.0 ( M S D ) . Fifty-seven percent of the clients were white and 36% black. The mean years of education was 10.6k1.9, with 81% having a minimum of one year high school education, 36% holding high school diplomas. Seventy-six percent of the clients were em- ployed full-time o r part-time prior to incarceration. The type of employment included primarily manual occupations such as con- struction, carpentry, truck driving, and kitchen help.

Participants were incarcerated for a variety of crimes including: possession of drugs and/or dangerous weapon, parole violat- tion, theft, rape, and murder. Sixty-eight percent were repeat offenders.

Materials

Three instruments were developed for the study. (1) A questionnaire, administered before and after the program, was designed


to assess client knowledge and attitudes in five content areas: knowledge regarding drugs ( 5 items), alcohol (6 items), and substance abuse treatment (7 items), and skills for managing stress ( 5 items), and anger (6 items). (2) Client rating forms enabled participants to evaluate their satisfaction with the program and group leaders, and how the program affected them. (3) Group leader rating forms were developed to measure group leaders’ evaluation of client participation, and attitude and behavior change regarding substance use.

Procedure

At the onset of the program clients completed a demographic information form and the knowledge and attitude questionnaire (pretest). At the end of the program clients completed the knowledge and attitude questionnaire again as a posttest measure of knowledge improvement and attitude change. They also filled out the form rating the program and group leaders. At the end of the program group leaders rated the participation of those ,clients who completed all sessions.

Program Evaluation

Effectiveness of program implementation was assessed by both process and outcome evaluations. The process evaluation measured the degree to which the program operated as intended. Ratings of client participation and group leader skills comprised this evaluation component. The outcome evaluation looked at knowledge and attitudes change brought about by the program. The outcome evaluation included objective and subjective assessments. Objective assessment, using a pretest-posttest analysis, measured the knowledge and attitude change of participants. Client and group leader estimates of attitude and behavior changes were the subjective assessments of program outcome.

RESULTS

Evaluation data were available for only those clients who completed the program. Court hearings and discharges prevented


several clients from completing the program, leaving a total of 32 clients upon whom the results are based.

Process Evaluation

Group Leader Ratings of Client Participation

Client participation was high, with 80% actively participating in group discussions (see Table 11). Also high was perceived interest in the program. More than three-quarters (87%) of the clients received an excellent or good rating in this area. The area rated lowest was insight. Slightly more than one-half (56%) of the clients were rated as having gained insight. An overall participation rating based on perceived interest, understanding of materials and respect for group rules and members was made by group leaders. More than three-quarters (80%) of the clients were rated as demonstrating excellent or good participation.

Table 11. Participant Ratings.

Group Leader Ratings of Client Participation

Excellent Good

Perceived interest 20% 6 7% Understanding materials 20% 60% Providing examples 13% 6 7%

Active Participation 33% 47%

Gaining insight 13% 44% Homework assignments 18% 55% Overall rating 13% 5 7%

Client Ratings of Group Leaders

Fair Poor 13% 7% 3% 10%

20% 0% 10% 10% 40% 3% 27% 0% 23% 7%

Concern Knowledge Respect Encouragement Support Helpfulness

Very Somewhat Not at All 93% 7% 0% 96% 4% 0% 96% 4% 0% 89% 11% 0% 85% 15% 0% 89% 11% 0% Excellent Good Fair Poor

Overall rating 63% 11% 26% 0%


Client Ratings of Group Leaders

Evaluations of group leaders were overwhelmingly positive. Seventy-four percent of the clients rated their group leader as excellent (63%) or good ( 1 1%) overall (see Table 11). Ratings were highest in the areas of knowledge and respect. Clients rated their group leader as either very (96%) or somewhat (4%) knowledge- able and respectful. Also high were ratings of group leaders concern and encouragement. Group leaders were rated as very or somewhat concerned by 93% and 7% of the clients, respectively. Eighty-nine percent and 11% of the clients found their group leader to be very or somewhat encouraging, respectively.

Outcome Evaluation

Objective Assessment

Results indicate a highly significant increase in participants' overall knowledge of program topics (see Table 111). Five content areas were covered in the program, four showing a statistically significant improvement in knowledge and attitudes.

Table 111. Percent of Correct Responses Pre-Program and Post-Programa

Pre-Program Post-Program t-test

50.63 66.25 4.02' 18.30 17.91 58.85 78.13 5.14' 15.25 17.68 73.39 76.61 0.54 25.77 28.09

18.41 18.12 58.93 69.64 2.58b 22.59 21.98 57.26 68.25 4.43c 12.81 14.82

Drug (W (SD>

Alcohol (W (SD)

Stress (W (SD>

Anger (XI (SD)

Treatment (W (SD)

Overall (W (SO)

55.36 63.39 2 . 1 9

'Note: N = 32 for all scores. Only those who completed program are rep-

bp < .05. resented.

c p < .001.


Drug and alcohol knowledge increased significantly. Scores on the drug subscale changed from a pretest mean of 50.63k18.30 to posttest of 66.25 k17.91, while mean scores on the alcohol subscale changed from 58.85k15.25 to 78.13k17.68. These changes were significant at the .001 level. This increase reflects an improved understanding of the effects and consequences of substance abuse. Improvement in scores was widespread with 69% of the clients improving their drug knowledge from pretest to posttest administration. Sixty-six percent of clients demonstrated improvement in alcohol knowledge.

Knowledge in the areas of substance abuse treatment and anger management skills increased significantly as well. Mean substance abuse treatment scores were 58.93 k22.59 (pretest) and 69.64k2 1.98 (posttest). Anger management subscale scores changed from a pretest mean of 55.36k18.41 to posttest of 63.39k18.12. Changes in both substance abuse treatment and anger management were significant at the .05 level. Fifty-three percent of the clients showed improvement in knowledge of anger management skills, while 44% improved in the area of substance abuse treatment.

The program was not effective in increasing client knowledge of stress management skills. Scores on the stress management subscale changed from a pretest mean of 73.39k25.77 t o posttest of 76.61528.09. This change was not significant at the .05 level. Only 36% of the clients showed improvement in this area.

Subjective Assessment

Client Ratings of Program. A subjective measure of program effectiveness was determined from client ratings (see Table IV). Clients rated all aspects of the program high with 10% rating the program as very (78%) or somewhat (22%) helpful overall. Effec- tiveness ratings ranged from 89% indicating the program was very helpful in alcohol education to 79% for providing substance treatment information.

Rating of Attitude and Behavior Change. One aim of the program was to change client attitudes and future drug and/or alcohol behavior. Two measures of the program’s success in attaining this goal were assessed independently by clients and group leaders (see Table V).

Substantial attitude and behavior change was reported by both

DRUG PREVENTION IN CORRECTIONS/6 1

Table IV. Client Ratings of Program.

Very Somewhat Not at All Helpful Helpful Helpful

Drug education 81% 19% 0% Alcohol education 89% 11% 0% Stress management skills 8 5% 15% 0% Anger management skills 82% 18% 0% Information about treatment 82% 1 8% 0% Overall helpfulness 7 8% 22% 0%

Table V. Ratings of Program Impact.

A Lot Some A Little None

~~ ~~

Change in Drug/Alcohol Attitudes

Client Rating Group Leader Rating

41% 30% 0%

29% 100% -

23% 40% 33% 3%

100% -

(N = 24) (N = 24)

Ch-square = 16.45, p < .01

Change in Future Drug/Alcohol Behavior

Client Rating Group Leader Rating

Decrease a Lot Decrease Somewhat Decrease a Little Remain the Same

56% 33% 0%

11% 100% -

33% 27% 10% 30%

100% -

(N = 24) (N = 24)

Chi-square = 11 .OO, p < .05

clients and group leaders. Seventy percent of the clients and 63% of the group leaders rated clients attitude changing a lot or somewhat. Eighty-nine percent of the clients and 60% of the group leaders rated client drug/alcohol behavior change as a lot or some-


what. However, different patterns emerged in client and group leader ratings. Clients tended to be more extreme in their ratings of attitude change. A large number of clients (70%) reported their attitudes changing a lot (41%) or not at all (29%). Group leader ratings, on the other hand, were less extreme with 73% rating client attitudes changing somewhat (40%) or a little (33%). In terms of behavior change, clients were more optimistic overall in their prediction of future drug and/or alcohol use. Clients tended to report future substance use as decreasing a lot (56%) or somewhat (33%). Group leaders were more conservative, with 30% reporting clients’ future drugfalcohol behavior would remain the same and 10% would decrease a little versus client predictions of 11 and 0%, respectively. Differences between client and group leader ratings of attitude and behavior change were examined; obtained chi square values of 16.5 and 11 .O were significant at the .01 and .05 levels, respectively.

DISCUSSION

The program was effective in increasing client knowledge of drugs and alcohol and changing attitudes toward substance use; and improving understanding of effective social skills. Clients showed marked improvement in overall knowledge of program topics. Knowledge improved in four of the five subareas; specifically, physiological effects of drugs and alcohol, anger management skills and substance abuse treatment. Areas of greatest improvement were drug and alcohol. Two-thirds of the clients increased their knowledge of these topics from pretest to posttest administration.

Although 36% of the clients showed improvement in knowledge of stress management skills, the improvement was not statistically significant. Plausible explanations for the failure of the program to increase knowledge of stress management skills include the small sample size, inadequate wording of test items, and deficiency in program content and/or delivery. One clue regarding these explanations is that client ratings indicate the program was effective in teaching stress management skills. This discrepancy between objective and subjective assessments of stress management knowledge suggests the likelihood of invalid test items.

Both clients and group leaders report the program was effec-


tive in facilitating drug and/or alcohol attitude and behavior change, although clients were somewhat more optimistic. Atti- tude and behavior ratings suggest the program’s effectiveness in changing attitudes which may in turn curtail future substance use upon release from the correctional facility.

The program was a positive experience for the participants. All clients rated the program excellent for education, helpfulness, and group leader effectiveness. Client participation in group sessions was rated high by group leaders. Favorable client and group leader ratings may have contributed to the significant increase in knowl-. edge and attitude change across program content areas. Jail officials also regarded the program positively and the program has been expanded subsequently to female inmates.

The treatment program is presented in its preliminary stages of development. Results obtained from this pilot study are being used to suggest modifications of program content and delivery and to refine evaluation instruments. Test items have been revised and discussions with group leaders are held on a regular basis to provide feedback about the program. In future studies, the authors hope to obtain larger samples and incorporate various improve- ments suggested by this investigation.

These findings and conclusions must be viewed with caution. The small subject sample and lack of a control group limit the ability to generalize the findings. However, the results suggest that a social competence approach to substance abuse rehabilitation in correctional institutions holds substantial promise.

Funding for this project was provided by the Baltimore City Health De- partment, Department of Addiction Services. The authors would like to acknowledge their assistance and that of the staff of Baltimore City Jail Treatment Services. This article was prepared for presentation at the annual meeting of the Association for Behavioral Analysis, Philadelphia, PA, May 1988.

References

Ballack, A. S., & Hersen, M. (1979). Research and practice in social skills training. New York: Plenum.

Botvin, G. J. (1983). Prevention of adolescent substance abuse through the development of personal and social competence. In T. J. Glynn, L. G. Leukefeld, & J. P. Lundford (Eds.), Preventing adolescent drug abuse:


Infervention strategies (NIDA Research Monograph No. 47, pp. 11 5- 140). Rockville, MD: National Institute on Drug Abuse.

Catalano, R. F., & Hawkins, J. D. (1985). Project skills: Preliminary results from a theoretically based aftercare experiment. In R. S. Ashery, (Ed.), Progress in the development of cost effective treatment for drug abusers (pp. 157-181). Washington, DC: National Institute on Drug Abuse, US Government Printing Office (#ADM 85-1401).

Chaney, E. F., OLeary, M. R., & Marlatt, G. A. (1978). Skill training with alcoholics. Journal of Gmsulting and Clinical Psychology, 46, 1092- 1104.

Donovan, D. M., & Chaney, E. F. (1985). Alcoholic relapse prevention and interventions: Models and methods. In G. A. Marlatt & J. R. Gordon (Eds.), Relapse prevention: A self-control strategy for the maintenance of behavior change (pp. 351-416). New York: Guilford.

Hawkins, J. D., Catalano, R. F., & Wells, E. A. (1986). Measuring effects of a skills training intervention on drug abusers. Journal of Consulting and Clinical Psychology, 54, 661 -664.

Jessor, R., & Jessor, S . L. (1977). Problem behavior and psychosocial development. New York: Academic.

Marlatt, G. A., & Gordon, J. R. (1980). Determinants of relapse: Implications for the maintenance of behavior change. In P. 0. Davidson & S. M. Davidson (Eds.), Behavioral medicine: Changing health lifestyles (pp. 410-454). New York: BrunnerlMazel.

Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: A self-control strategy for the maintenance of behavior change. New York: Guilford.

Miller, P. M., & Eisler, R. M. (1977). Assertive behavior of alcoholics: A de- scriptive approach. Behavior Therapy, 8, 146-149.

Pentz, M. A. (1981). The contribution of individual differences to assertion training outcome in adolescents. Journal of Counseling Psychology, 6,

Rist, F., & Watzel, H. (1983). Self assessment of relapse risk and assertiveness in relation to treatment outcome of female alcoholics. Addictive Behav- iors, 8, 121-127.

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