Transcript Menu of Programs - Organization of American States

Elements of an Effective Substance
Abuse Treatment Model for Offenders
Correctional Service of Canada’s Model
Overview
Research-based Offender Treatment
• Part I: Effective Intervention
 Substance use and abuse
 Components of Effective Substance Abuse
Interventions
• Part III: Effective Programming
 Components of Effective Substance Abuse Programs
 Overview of CSC’s Substance Abuse Programs
• Part IV: Maintenance and Aftercare
 Principles of Relapse Prevention
 Factors to consider
• Part VI: Service Quality and Monitoring
 Program Management
Research Based Offender
Treatment (Part I)
Effective Intervention
 Substance Abuse: Stages of
Acquisition & Intervention
 Models and implications for
treatment
 Principles of Effective Intervention
 Best practices in intervention
Substance Abuse:
Stages of Acquisition & Intervention
Non-problematic
First
Substance
Initial
Substance Substance
Experimentation
Dependence
Abstinence
Use
Use
Primary
Prevention
Secondary
Prevention
Treatment
Models and Implications for
Treatment
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The way substance abuse is
understood influences the mode of
intervention, e.g., Brickman’s Model
Substance Abuse:
Brickman’s Model
Is the Person Responsible for
Changing the Addictive Behavior?
YES
Is the
Person
Responsible
for the
Development
of the
Addictive
Behavior?
Development
of the
Addictive
NO
YES
NO
MORAL MODEL
(War on Drugs)
SPIRITUAL MODEL
(AA & 12-Steps)
Relapse = A Crime or
a Lack of Willpower
Relapse = Sin or
Loss of Contact with
Higher Power
COMPENSATORY MODEL
(Cognitive-Behavioral)
DISEASE MODEL
(Heredity & Physiology)
Relapse = Mistake, Error,
or Temporary Setback
Relapse = Reactivation of
Progressive Disease
Models and Implications for
Treatment
Selection of an over-arching approach
to intervention based on:
 Principles of effective correctional
intervention
 Best practices literature
Principles of Effective Correctional
Programs
Andrews (2000) Principles
 Intervention based on a psychological
theory of criminal behaviour that includes
a general personality and social learning
approach
 Introduce human service strategies – do
not rely on principles of retribution,
restorative justice, deterrence or
incarceration
 Community-based services are preferred
 Match intensity of intervention to level of
risk
Principles of Effective Correctional
Programs
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Target known criminogenic need –
multimodal is best, i.e., multi-need
Assessment of risk and need must be
based on reliable and valid tools
Address responsivity and strength factors
Must include aftercare
Develop individualized plans
Integrity of program implementation and
delivery
Attend to staff, managers and the broader
social context
Summary of Best Practices*
Treatment with support:
 Pharmacological intervention has a role –
with conditions and requires treatment
 Behavioural relapse prevention programs
 Community reinforcement
 Martial therapy
 Social skills training
 Stress management
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*Health Canada (1999) Best Practices: Substance Abuse treatment and rehabilitation
Best Practices Summary
Effective Treatment Factors:
 Programming matching is needed
 Treatment should be in a group format
unless contraindicated
 Outpatient treatment is cost-effective
 Brief interventions only with stable
individuals with low to moderate problems
 Treatment effect enhanced by competent
service providers
Best Practices Summary
Intervention with Specialized Groups
 Some evidence for the efficacy of
mandated treatment
 Insufficient evidence to support provision
of specific types of interventions to women
 Adolescents need flexible approaches
 Seniors benefit from community-based
treatments
 Integrate services for dually diagnosed
individuals
Effective Intervention
Operationalising “what works”
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Substance use falls along a continuum
The intensity of the intervention matches severity
of problem
Create and mobilize community-based resources
for primary and secondary interventions
Cognitive-behavioural models integrating relapse
prevention are effective models of treatment
Provide group interventions
Include harm reduction strategies
Ensure integrity in program delivery and
management
Research-based Intervention for
Offenders – Part III
Elements of Effective Programming
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Empirically supported model
Effective methods for intervention
Multimodal approach to intervention
CSC’s Substance Abuse Programs
Empirically Supported Model
Cognitive-Behavioural Model
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Addictive behaviours are as a result of the
interaction between biological, psychological and
sociocultural factors
Addictive behaviours are maladaptive because
they are the central or sole means to feel
pleasure and to deal with life’s demands
Changing behaviour and thinking will modify
existing patterns
Relapse Prevention
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Most people don’t successfully change behaviour
on first effort
Individuals identify their risk factors and broaden
ways to cope in order to decrease likelihood of
lapsing or relapsing into old patterns
Effective Methods
The intervention is most effective
when it is:
• Structured
• Has built in reinforcement,
modelling and skills acquisition
through role-plays, graduated
approximations and extinction
• Responsivity factors are identified
and addressed
Effective Methods
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Same processes that maintain
substance abusing behaviours are
used in treatment to change patterns
(Reinforcement, modelling , skill
acquisition through role-play and
graduated approximations, cognitive
restructuring)
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Motivational enhancement strategies
Harm reduction model
Multi-modal Interventions
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Assertion training
Social skills
training
Problem solving
Controlled drinking
strategies
Methadone
maintenance
Employment
training
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Recognition of high
risk situations
Relapse prevention
Behavioural selfcontrol
Stress
management
Marital
Aftercare
CSC’s Integrated Model of Change
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Psychology of Criminal Conduct
(Andrews & Bonta)
Social Cognitive Theory (Bandura)
Cognitive Behavioural
Relapse Prevention Therapy (Parks &
Marlatt)
Coping Model of Criminal Recidivism
(Zamble & Quinsey)
Transtheoretical Model of Change
Integrated Model
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Crime because learning and skills deficits
Substance abuse because of learning,
dependency and deficits
Beh’r is maintained by past learning, including
peer modeling, reinforcement contingencies,
cognitive expectations, and biological
influences
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Substance abuse and crime linked
Change patterns of substance abuse to
decrease relapse and recidivism
Motivational enhancement necessary to
facilitate change
CSC’s National Substance Abuse
Programs (NSAP)
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There are three levels of program
intensity to address differing severity
of problem – high, moderate and low
Programming starts at the beginning
of the sentence, where warranted
Aftercare is mandatory
Program Timing
Assessed
Level of
Need
Institution
High
NSAP
High
Moderate
NSAP
Mod
Low
M
A
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N
T
E
N
A
N
C
E
Community
PreRelease
Booster
NSAP
low
M
A
I
N
T
E
N
A
N
C
E
Menu of Programs
CSC’s application of Effective
Program Methods
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Programs are structured with a “scripted”
manual for facilitators to follow
Programs based on the principles of adult
learning
Offenders guided to see personal
relevance of the content
All skills are introduced, modelled and
reinforced and frequently practiced
Facilitators sensitised to responsivity
factors and given guidance to address
Skills in CSC’s Programs
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Self-control training: self-monitoring,
goal setting,
Identification of high risk situations
Problem solving to deal with triggers
Relapse prevention strategies to manage
triggers
Cognitive coping: ABC model to identify risky thinking
and beliefs, to counter outcome expectancies; inoculation to
come up with positive coping thoughts
Behavioural coping:
Craving management
Intrapersonal control: time out, counting down, breathing
techniques
Social skills: listening, receiving feedback, assertion,
negotiation, dealing with pressure, asking for help, expressing
negative feelings, conflict management, empathy building,
perspective taking and community building
Where it fits
Self
Monitoring
+
Assessment
High Risk
Situation
Analysis of
Relapses
Efficacy
Enhancing
Imagery
+
Emotional
Regulation
Ineffective
Coping
Competency
Assessment
+
Skills Training
+
Relapse
Prevention
Rehearsal
Limit use
+
Slip
Management
Decreased
Self Efficacy
+
POE
Decision
Matrix
+
Lt vs ST
Effects
LAPSE
Violation
Effect
Emergency Cognitive
Relapse Restructuring
Plan
Program Phases
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All NSAP intensities have same
phases
Phase I: Deciding What I would Like
to Change
Phase II: Improving the Odds
Phase III: Learning the tools for
Change
Phase IV: Using the Skills and
Planning for my Future
Phase I
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Goal is to illustrate how participants
became dependent upon substances, how
it is connected with their criminal
behaviour and the consequences of this
across all life domains
Personal goal setting
Identification of obstacles and selfmanagement deficiencies
Self-monitoring
POE related to crime and drugs
basic social and intrapersonal skills
Coping with cravings and urges
Phase II
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Goal is to have participants recognise their
internal and external risk factors
Use Inventory of Drug/Drinking Situations
to identify HRS
Marlatt’s model of Relapse Prevention
How triggers effect them (T-D-G) and how
they build (G-Y-R)
Development of integrated crime and
substance abuse cycles
Problem solving steps to disrupt the cycles
Phase III
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Learning Coping by Thinking and Coping
by Doing skills to create a different life (4
key life areas)
Using Cognitive and Behavioural Coping to
develop
• Better relationships: intimate partners, friends, others
authority
• Feeling good – enhancing sense of self, emotion
management, mental health
• Personal control and freedom – putting in place things to
stop the return to substance misuse
• Satisfying life
Phase IV
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Goal is to finalize the recidivism and
relapse prevention plans
Development of life area plans for:
substance use, work/school/finance,
relationships, leisure, legal, health and
well-being, and community building
Evaluate RP and life area plans
Set goals for continued change and
monitoring
Research Based Offender
Treatment – Part IV
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Maintenance and Aftercare
Why Maintenance
Maintenance
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Research supports that aftercare
maximizes effectiveness
Maintenance reinforces and
strengthens progress made in
treatment – reflects the principles of
relapse prevention
Maintenance
Factors to consider:
 Frequency of contact based on
stability and functioning – external
monitoring function
 Relevant for current life
circumstances
 Evaluation and enhancement of skill
set
Maintenance
CSC’s aftercare for offenders with
substance abuse problems:
 Institutional Substance Abuse
Maintenance Program
 Pre-Release Boosters
 Community Substance Abuse
Maintenance Program
 Community Maintenance Program
Research-based Offender
Treatment – Part VI
Service Quality and Monitoring
 Program Management
• Considerations for successful
implementation
• Staff Training and Quality Assurance
• Research and Evaluation
• Accreditation of Programs
Program Management
Considerations for successful program
implementation
 Sincere motivation
 Support at the top
 Staff competence
 Cost-benefit surplus
 Clarity of goals and procedures
 Clear lines of authority
 Implementation evaluation
 Program evaluation framework
Program Management
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What to evaluate
• Direction. Requires strategic planning,
mission statement with corresponding
policy, clear goals and objectives
• Existing conditions
• Application of the principles of matching
• Implementation of appropriate
intervention
• Therapeutic integrity
• Evaluation of staff
Program Management
Staff Training and Quality Assurance
 Staff selection is critical
 Well trained, supervised and supported
staff are necessary
• CSC’s infrastructure includes National,
Regional, and local management
• Program manual and staff training manual for
consistency
• Program deliverers are monitored for
compliance and efficacy, when warranted they
are certified, and have ongoing follow-up
Program Management
Research and Evaluation
 Program evaluation is necessary to
assess efficacy, cost-effectiveness
and inform ongoing program
development
 Evaluation commenced immediately
upon implementation
Outcome Data
CSC’s original programs
 Offenders who completed high intensity
program demonstrated a 19% reduction in
readmission and a 50% reduction in new
convictions
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High intensity program participants were
less likely to be readmitted (37% vs.
45%) to custody and were slightly less
likely to have their conditional release
revoked as a result of a new offence (4%
vs. 8%).
Outcome data
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Offenders completed the moderate
intensity intervention and showed a 14%
reduction in re-admission (from 49% to
42%) and 31% reduction in new
convictions (from 21.9% to 15.2%)
Offenders, who completed the low
intensity, plus maintenance, had a 29%
reduction in readmission.
There was a 56% reduction in reconvictions for those who completed
maintenance.
Program Management
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Unit costs for high, moderate, low
and maintenance intervention
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Unit costs of in-patient treatment
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High - $6,758
Moderate – $1,100
$Low – $900
$Maintenance - $364
$12, 079
Preliminary data support cost
effectiveness of intervention
Program Management
Accreditation of Programs
 International panel reviews to ensure that
new programs meet highest standards
 NSAP accredited in December 2003
 8 criteria: explicit, empirically-based model of
change, targets criminogenic needs, uses
effective methods, is skills oriented, addresses
responsivity factors, intensity related to severity
of problem, offers continuity of care, and has
ongoing monitoring and evaluation
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After initial accreditation, programs are on
a 5 year cycle