Elements of an Effective Substance Elements of an Effective Substance Abuse Treatment Model for OffendersAbuse Treatment Model for Offenders

Correctional Service of Canada’s ModelCorrectional Service of Canada’s Model

OverviewOverview

Research-based Offender TreatmentResearch-based Offender Treatment• Part I: Effective InterventionPart I: Effective Intervention

Substance use and abuseSubstance use and abuse Components of Effective Substance Abuse Components of Effective Substance Abuse

InterventionsInterventions• Part III: Effective ProgrammingPart III: Effective Programming

Components of Effective Substance Abuse ProgramsComponents of Effective Substance Abuse Programs Overview of CSC’s Substance Abuse ProgramsOverview of CSC’s Substance Abuse Programs

• Part IV: Maintenance and AftercarePart IV: Maintenance and Aftercare Principles of Relapse PreventionPrinciples of Relapse Prevention Factors to considerFactors to consider

• Part VI: Service Quality and MonitoringPart VI: Service Quality and Monitoring Program ManagementProgram Management

Research Based Offender Research Based Offender Treatment (Part I)Treatment (Part I)

Effective InterventionEffective Intervention Substance Abuse: Stages of Substance Abuse: Stages of

Acquisition & InterventionAcquisition & Intervention Models and implications for Models and implications for

treatmenttreatment Principles of Effective InterventionPrinciples of Effective Intervention Best practices in interventionBest practices in intervention

Substance Abuse:Substance Abuse:Stages of Acquisition & InterventionStages of Acquisition & Intervention

InitialAbstinence

FirstExperimentation

Non-problematicSubstance

UseSubstance

Use

SubstanceDependence

Primary Prevention

SecondaryPrevention

Treatment

Models and Implications for Models and Implications for TreatmentTreatment

The way substance abuse is The way substance abuse is understood influences the mode of understood influences the mode of intervention, e.g., Brickman’s Modelintervention, e.g., Brickman’s Model

Substance Abuse:Substance Abuse:Brickman’s ModelBrickman’s Model

Is the Person Responsible for

Changing the Addictive Behavior?

YES

NO

YES Is the Person Responsible for the Development of the Addictive

MORAL MODEL (War on Drugs)

Relapse = A Crime or a Lack of Willpower

SPIRITUAL MODEL (AA & 12-Steps)

Relapse = Sin or

Loss of Contact with Higher Power

Development of the Addictive Behavior?

NO

COMPENSATORY MODEL (Cognitive-Behavioral)

Relapse = Mistake, Error,

or Temporary Setback

DISEASE MODEL (Heredity & Physiology)

Relapse = Reactivation of

Progressive Disease

Models and Implications for Models and Implications for TreatmentTreatment

Selection of an over-arching approach Selection of an over-arching approach to intervention based on:to intervention based on:

Principles of effective correctional Principles of effective correctional interventionintervention

Best practices literatureBest practices literature

Principles of Effective Correctional Principles of Effective Correctional ProgramsPrograms

Andrews (2000) PrinciplesAndrews (2000) Principles Intervention based on a psychological theory Intervention based on a psychological theory

of criminal behaviour that includes a general of criminal behaviour that includes a general personality and social learning approachpersonality and social learning approach

Introduce human service strategies – do not Introduce human service strategies – do not rely on principles of retribution, restorative rely on principles of retribution, restorative justice, deterrence or incarcerationjustice, deterrence or incarceration

Community-based services are preferredCommunity-based services are preferred Match intensity of intervention to level of riskMatch intensity of intervention to level of risk

Principles of Effective Correctional Principles of Effective Correctional ProgramsPrograms

Target known criminogenic need – Target known criminogenic need – multimodal is best, i.e., multi-needmultimodal is best, i.e., multi-need

Assessment of risk and need must be Assessment of risk and need must be based on reliable and valid toolsbased on reliable and valid tools

Address responsivity and strength factorsAddress responsivity and strength factors Must include aftercareMust include aftercare Develop individualized plansDevelop individualized plans Integrity of program implementation and Integrity of program implementation and

deliverydelivery Attend to staff, managers and the broader Attend to staff, managers and the broader

social context social context

Summary of Best Practices*Summary of Best Practices*

Treatment with support:Treatment with support: Pharmacological intervention has a role – Pharmacological intervention has a role –

with conditions and requires treatmentwith conditions and requires treatment Behavioural relapse prevention programs Behavioural relapse prevention programs Community reinforcement Community reinforcement Martial therapyMartial therapy Social skills trainingSocial skills training Stress managementStress management

*Health Canada (1999) Best Practices: Substance Abuse treatment and rehabilitation*Health Canada (1999) Best Practices: Substance Abuse treatment and rehabilitation

Best Practices SummaryBest Practices Summary

Effective Treatment Factors:Effective Treatment Factors: Programming matching is neededProgramming matching is needed Treatment should be in a group format Treatment should be in a group format

unless contraindicatedunless contraindicated Outpatient treatment is cost-effectiveOutpatient treatment is cost-effective Brief interventions only with stable Brief interventions only with stable

individuals with low to moderate problemsindividuals with low to moderate problems Treatment effect enhanced by competent Treatment effect enhanced by competent

service providersservice providers

Best Practices SummaryBest Practices Summary

Intervention with Specialized GroupsIntervention with Specialized Groups Some evidence for the efficacy of Some evidence for the efficacy of

mandated treatment mandated treatment Insufficient evidence to support provision Insufficient evidence to support provision

of specific types of interventions to womenof specific types of interventions to women Adolescents need flexible approachesAdolescents need flexible approaches Seniors benefit from community-based Seniors benefit from community-based

treatmentstreatments Integrate services for dually diagnosed Integrate services for dually diagnosed

individuals individuals

Effective InterventionEffective Intervention

Operationalising “what works”Operationalising “what works” Substance use falls along a continuum Substance use falls along a continuum The intensity of the intervention matches severity The intensity of the intervention matches severity

of problemof problem Create and mobilize community-based resources Create and mobilize community-based resources

for primary and secondary interventionsfor primary and secondary interventions Cognitive-behavioural models integrating relapse Cognitive-behavioural models integrating relapse

prevention are effective models of treatmentprevention are effective models of treatment Provide group interventions Provide group interventions Include harm reduction strategiesInclude harm reduction strategies Ensure integrity in program delivery and Ensure integrity in program delivery and

managementmanagement

Research-based Intervention for Research-based Intervention for Offenders – Part IIIOffenders – Part III

Elements of Effective ProgrammingElements of Effective Programming

Empirically supported model Empirically supported model Effective methods for interventionEffective methods for intervention Multimodal approach to interventionMultimodal approach to intervention CSC’s Substance Abuse ProgramsCSC’s Substance Abuse Programs

Empirically Supported ModelEmpirically Supported Model

Cognitive-Behavioural ModelCognitive-Behavioural Model Addictive behaviours are as a result of the interaction Addictive behaviours are as a result of the interaction

between biological, psychological and sociocultural between biological, psychological and sociocultural factorsfactors

Addictive behaviours are maladaptive because they Addictive behaviours are maladaptive because they are the central or sole means to feel pleasure and to are the central or sole means to feel pleasure and to deal with life’s demandsdeal with life’s demands

Changing behaviour and thinking will modify existing Changing behaviour and thinking will modify existing patternspatterns

Relapse PreventionRelapse Prevention Most people don’t successfully change behaviour on Most people don’t successfully change behaviour on

first effortfirst effort Individuals identify their risk factors and broaden ways Individuals identify their risk factors and broaden ways

to cope in order to decrease likelihood of lapsing or to cope in order to decrease likelihood of lapsing or relapsing into old patternsrelapsing into old patterns

Effective MethodsEffective Methods

The intervention is most effective The intervention is most effective when it is:when it is:

• StructuredStructured• Has built in reinforcement, Has built in reinforcement,

modelling and skills acquisition modelling and skills acquisition through role-plays, graduated through role-plays, graduated approximations and extinctionapproximations and extinction

• Responsivity factors are identified Responsivity factors are identified and addressedand addressed

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

Motivational enhancement strategiesMotivational enhancement strategies Harm reduction modelHarm reduction model

Effective MethodsEffective Methods

Assertion trainingAssertion training Social skills Social skills

trainingtraining Problem solvingProblem solving Controlled drinking Controlled drinking

strategiesstrategies Methadone Methadone

maintenancemaintenance Employment Employment

trainingtraining

Recognition of high Recognition of high risk situationsrisk situations

Relapse preventionRelapse prevention Behavioural self-Behavioural self-

controlcontrol Stress Stress

managementmanagement Marital Marital Aftercare Aftercare

Multi-modal InterventionsMulti-modal Interventions

Psychology of Criminal Conduct Psychology of Criminal Conduct (Andrews & Bonta)(Andrews & Bonta)

Social Cognitive Theory (Bandura)Social Cognitive Theory (Bandura) Cognitive Behavioural Cognitive Behavioural Relapse Prevention Therapy (Parks & Relapse Prevention Therapy (Parks &

Marlatt)Marlatt) Coping Model of Criminal Recidivism Coping Model of Criminal Recidivism

(Zamble & Quinsey)(Zamble & Quinsey) Transtheoretical Model of ChangeTranstheoretical Model of Change

CSC’s Integrated Model of ChangeCSC’s Integrated Model of Change

Integrated ModelIntegrated Model Crime because learning and skills deficitsCrime because learning and skills deficits Substance abuse because of learning, Substance abuse because of learning,

dependency and deficitsdependency and deficitsBeh’r is maintained by past learning, including Beh’r is maintained by past learning, including

peer modeling, reinforcement contingencies, peer modeling, reinforcement contingencies, cognitive expectations, and biological cognitive expectations, and biological influencesinfluences

Substance abuse and crime linkedSubstance abuse and crime linked Change patterns of substance abuse to Change patterns of substance abuse to

decrease relapse and recidivismdecrease relapse and recidivism Motivational enhancement necessary to Motivational enhancement necessary to

facilitate changefacilitate change

CSC’s National Substance Abuse CSC’s National Substance Abuse Programs (NSAP)Programs (NSAP)

There are three levels of program There are three levels of program intensity to address differing severity intensity to address differing severity of problem – high, moderate and lowof problem – high, moderate and low

Programming starts at the beginning Programming starts at the beginning of the sentence, where warrantedof the sentence, where warranted

Aftercare is mandatoryAftercare is mandatory

Program TimingProgram Timing

Assessed Assessed

Level of Level of NeedNeed

InstitutionInstitution CommunityCommunity

HighHigh

ModerateModerate

LowLow

NSAPHigh

NSAPMod

Pre-ReleaseBooster

MAINTENANCE

MAINTENANCENSAP

low

Menu of ProgramsMenu of Programs

CSC’s application of Effective CSC’s application of Effective Program MethodsProgram Methods

Programs are structured with a “scripted” Programs are structured with a “scripted” manual for facilitators to followmanual for facilitators to follow

Programs based on the principles of adult Programs based on the principles of adult learning learning

Offenders guided to see personal Offenders guided to see personal relevance of the contentrelevance of the content

All skills are introduced, modelled and All skills are introduced, modelled and reinforced and frequently practicedreinforced and frequently practiced

Facilitators sensitised to responsivity Facilitators sensitised to responsivity factors and given guidance to address factors and given guidance to address

Skills in CSC’s ProgramsSkills in CSC’s Programs Self-control trainingSelf-control training: self-monitoring, : self-monitoring,

goal setting, goal setting, Identification of high risk situationsIdentification of high risk situations Problem solvingProblem solving to deal with triggers to deal with triggers Relapse prevention strategiesRelapse prevention strategies to manage to manage

triggerstriggers Cognitive copingCognitive coping: ABC model to identify risky thinking : ABC model to identify risky thinking

and beliefs, to counter outcome expectancies; inoculation to and beliefs, to counter outcome expectancies; inoculation to come up with positive coping thoughtscome up with positive coping thoughts

Behavioural copingBehavioural coping: : Craving management Craving management Intrapersonal controlIntrapersonal control: time out, counting down, breathing : time out, counting down, breathing

techniquestechniques Social skillsSocial skills: listening, receiving feedback, assertion, : listening, receiving feedback, assertion,

negotiation, dealing with pressure, asking for help, expressing negotiation, dealing with pressure, asking for help, expressing negative feelings, conflict management, empathy building, negative feelings, conflict management, empathy building, perspective taking and community building perspective taking and community building

High RiskSituation

IneffectiveCoping

Decreased Self Efficacy

+ POE

LAPSEViolation

Effect

Analysis ofRelapses

SelfMonitoring

+Assessment

CompetencyAssessment

+Skills Training

+Relapse

PreventionRehearsal

Decision Matrix

+Lt vs STEffects

EmergencyRelapse

Plan

CognitiveRestructuring

EfficacyEnhancingImagery

+EmotionalRegulation

Limit use+

SlipManagement

Where it fitsWhere it fits

Program PhasesProgram Phases

All NSAP intensities have same All NSAP intensities have same phasesphases

Phase I: Deciding What I would Like Phase I: Deciding What I would Like to Changeto Change

Phase II: Improving the OddsPhase II: Improving the Odds Phase III: Learning the tools for Phase III: Learning the tools for

ChangeChange Phase IV: Using the Skills and Phase IV: Using the Skills and

Planning for my FuturePlanning for my Future

Phase IPhase I Goal is to illustrate how participants Goal is to illustrate how participants

became dependent upon substances, how became dependent upon substances, how it is connected with their criminal it is connected with their criminal behaviour and the consequences of this behaviour and the consequences of this across all life domainsacross all life domains

Personal goal settingPersonal goal setting Identification of obstacles and self-Identification of obstacles and self-

management deficienciesmanagement deficiencies Self-monitoringSelf-monitoring POE related to crime and drugsPOE related to crime and drugs basic social and intrapersonal skillsbasic social and intrapersonal skills Coping with cravings and urgesCoping with cravings and urges

Phase IIPhase II

Goal is to have participants recognise their Goal is to have participants recognise their internal and external risk factorsinternal and external risk factors

Use Inventory of Drug/Drinking Situations Use Inventory of Drug/Drinking Situations to identify HRSto identify HRS

Marlatt’s model of Relapse PreventionMarlatt’s model of Relapse Prevention How triggers effect them (T-D-G) and how How triggers effect them (T-D-G) and how

they build (G-Y-R)they build (G-Y-R) Development of integrated crime and Development of integrated crime and

substance abuse cyclessubstance abuse cycles Problem solving steps to disrupt the cyclesProblem solving steps to disrupt the cycles

Phase IIIPhase III Learning Coping by Thinking and Coping Learning Coping by Thinking and Coping

by Doing skills to create a different life (4 by Doing skills to create a different life (4 key life areas)key life areas)

Using Cognitive and Behavioural Coping to Using Cognitive and Behavioural Coping to developdevelop• Better relationships: intimate partners, friends, others Better relationships: intimate partners, friends, others

authorityauthority• Feeling good – enhancing sense of self, emotion Feeling good – enhancing sense of self, emotion

management, mental healthmanagement, mental health• Personal control and freedom – putting in place things to Personal control and freedom – putting in place things to

stop the return to substance misusestop the return to substance misuse• Satisfying lifeSatisfying life

Phase IVPhase IV

Goal is to finalize the recidivism and Goal is to finalize the recidivism and relapse prevention plans relapse prevention plans

Development of life area plans for: Development of life area plans for: substance use, work/school/finance, substance use, work/school/finance, relationships, leisure, legal, health and relationships, leisure, legal, health and well-being, and community buildingwell-being, and community building

Evaluate RP and life area plansEvaluate RP and life area plans Set goals for continued change and Set goals for continued change and

monitoring monitoring

Research Based Offender Research Based Offender Treatment – Part IVTreatment – Part IV

Maintenance and AftercareMaintenance and Aftercare Why MaintenanceWhy Maintenance

MaintenanceMaintenance

Research supports that aftercare Research supports that aftercare maximizes effectivenessmaximizes effectiveness

Maintenance reinforces and Maintenance reinforces and strengthens progress made in strengthens progress made in treatment – reflects the principles of treatment – reflects the principles of relapse preventionrelapse prevention

MaintenanceMaintenance

Factors to consider:Factors to consider: Frequency of contact based on Frequency of contact based on

stability and functioning – external stability and functioning – external monitoring functionmonitoring function

Relevant for current life Relevant for current life circumstancescircumstances

Evaluation and enhancement of skill Evaluation and enhancement of skill setset

MaintenanceMaintenance

CSC’s aftercare for offenders with CSC’s aftercare for offenders with substance abuse problems:substance abuse problems:

Institutional Substance Abuse Institutional Substance Abuse Maintenance ProgramMaintenance Program

Pre-Release BoostersPre-Release Boosters Community Substance Abuse Community Substance Abuse

Maintenance ProgramMaintenance Program Community Maintenance ProgramCommunity Maintenance Program

Research-based Offender Research-based Offender Treatment – Part VITreatment – Part VI

Service Quality and MonitoringService Quality and Monitoring Program ManagementProgram Management

• Considerations for successful Considerations for successful implementationimplementation

• Staff Training and Quality AssuranceStaff Training and Quality Assurance• Research and EvaluationResearch and Evaluation• Accreditation of ProgramsAccreditation of Programs

Program ManagementProgram Management

Considerations for successful program Considerations for successful program implementationimplementation

Sincere motivationSincere motivation Support at the topSupport at the top Staff competenceStaff competence Cost-benefit surplusCost-benefit surplus Clarity of goals and proceduresClarity of goals and procedures Clear lines of authorityClear lines of authority Implementation evaluationImplementation evaluation Program evaluation frameworkProgram evaluation framework

Program ManagementProgram Management

What to evaluateWhat to evaluate• Direction. Requires strategic planning, Direction. Requires strategic planning,

mission statement with corresponding mission statement with corresponding policy, clear goals and objectivespolicy, clear goals and objectives

• Existing conditions Existing conditions • Application of the principles of matchingApplication of the principles of matching• Implementation of appropriate Implementation of appropriate

interventionintervention• Therapeutic integrityTherapeutic integrity• Evaluation of staffEvaluation of staff

Program ManagementProgram Management

Staff Training and Quality AssuranceStaff Training and Quality Assurance Staff selection is critical Staff selection is critical Well trained, supervised and supported Well trained, supervised and supported

staff are necessarystaff are necessary• CSC’s infrastructure includes National, CSC’s infrastructure includes National,

Regional, and local managementRegional, and local management• Program manual and staff training manual for Program manual and staff training manual for

consistencyconsistency• Program deliverers are monitored for Program deliverers are monitored for

compliance and efficacy, when warranted they compliance and efficacy, when warranted they are certified, and have ongoing follow-upare certified, and have ongoing follow-up

Program ManagementProgram Management

Research and EvaluationResearch and Evaluation Program evaluation is necessary to Program evaluation is necessary to

assess efficacy, cost-effectiveness assess efficacy, cost-effectiveness and inform ongoing program and inform ongoing program developmentdevelopment

Evaluation commenced immediately Evaluation commenced immediately upon implementationupon implementation

Outcome DataOutcome Data

CSC’s original programsCSC’s original programs Offenders who completed high intensity Offenders who completed high intensity

program demonstrated a 19% reduction in program demonstrated a 19% reduction in readmission and a 50% reduction in new readmission and a 50% reduction in new convictionsconvictions

High intensity program participants were High intensity program participants were less likely to be readmitted (37% vs. 45%) less likely to be readmitted (37% vs. 45%) to custody and were slightly less likely to to custody and were slightly less likely to have their conditional release revoked as a have their conditional release revoked as a result of a new offence (4% vs. 8%). result of a new offence (4% vs. 8%).

Outcome dataOutcome data

Offenders completed the moderate Offenders completed the moderate intensity intervention and showed a 14% intensity intervention and showed a 14% reduction in re-admission (from 49% to reduction in re-admission (from 49% to 42%) and 31% reduction in new 42%) and 31% reduction in new convictions (from 21.9% to 15.2%)convictions (from 21.9% to 15.2%)

Offenders, who completed the low Offenders, who completed the low intensity, plus maintenance, had a 29% intensity, plus maintenance, had a 29% reduction in readmission. reduction in readmission.

There was a 56% reduction in re-There was a 56% reduction in re-convictions for those who completed convictions for those who completed maintenance. maintenance.

Program ManagementProgram Management

Unit costs for high, moderate, low Unit costs for high, moderate, low and maintenance interventionand maintenance intervention

High - $6,758High - $6,758 Moderate – $1,100Moderate – $1,100 $Low – $900$Low – $900 $Maintenance - $364$Maintenance - $364

Unit costs of in-patient treatmentUnit costs of in-patient treatment $$12, 07912, 079

Preliminary data support cost Preliminary data support cost effectiveness of interventioneffectiveness of intervention

Program ManagementProgram Management

Accreditation of ProgramsAccreditation of Programs International panel reviews to ensure that International panel reviews to ensure that

new programs meet highest standardsnew programs meet highest standards NSAP accredited in December 2003NSAP accredited in December 2003 8 criteria: 8 criteria: explicit, empirically-based model of explicit, empirically-based model of

change, targets criminogenic needs, uses change, targets criminogenic needs, uses effective methods, is skills oriented, addresses effective methods, is skills oriented, addresses responsivity factors, intensity related to severity responsivity factors, intensity related to severity of problem, offers continuity of care, and has of problem, offers continuity of care, and has ongoing monitoring and evaluationongoing monitoring and evaluation

AfterAfter initial accreditation, programs are on initial accreditation, programs are on a 5 year cyclea 5 year cycle