Upload
diana-french
View
218
Download
1
Tags:
Embed Size (px)
Citation preview
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