The Effectiveness of Substance Abuse Treatment with Young Offenders
- 3.3 Post-treatment factors
- 3.4 Additional considerations
3. Substance Abuse Treatment for Youthful Offenders: What Works! (cont'd)
Aftercare is defined as providing therapeutic activities and support to the substance abusing client following program completion, to help ensure the gains he/she made during treatment generalize to the community (Correctional Services Canada, 1996; Lurigio, 2000; Sealock et al., 1997). This transference of treatment gains is necessary because one of the major criticisms lodged against substance abuse treatment is that, given the complexity of the problem, it is naïve to expect that changes observed within a residential setting will transfer successfully to the community (Stein, Garrett, & Christiansen, 1990).
One of the reasons why aftercare has been viewed as a critical success factor in the delivery of effective substance abuse treatment programs is the fact that past research has demonstrated that roughly 50% of the variation in post-release failure in adult populations can be attributed to post-treatment factors (e.g., family support) (Moos, Finney, & Cronkite, 1990). Unfortunately, comparable data is not currently available in the adolescent substance abuse treatment literature and highlights a significant knowledge gap (Latimer et al., 2000).
Despite the intuitive appeal of this form of programming, very few studies involving correctional populations have examined aftercare impacts (Sealock et al., 1997). Two recent meta-analyses of the correctional treatment literature have provided preliminary evidence in this regard and have shown that programs that incorporate elements of aftercare sessions into their program model yield moderate programmatic improvements in the treatment group (Dowden et al., in press; Dowden et al., in preparation).
Past research has demonstrated that there is considerable individual variability in terms of how adolescents respond to the same risk factors. Accordingly, experts in the field have attempted to identify protective or strength factors, which contribute to the resilience of these juveniles from risky situations and mark a relatively new line of scientific inquiry within the field of adolescent substance abuse treatment.
Protective factors are separate from risk factors and should not be viewed as the absence of risk factors (Gilvarry, 2000). In addition, assuming that protective and risk factors operate at opposite ends of the same continuum is incorrect as this claim has yet to be verified (Newcomb & Felix-Ortiz, 1992; Rutter, 1991). More precisely, these factors may moderate the risk of substance misuse, or in the ideal scenario, make the youth more resilient when faced with potentially harmful situations (Newcomb, & Bentler, 1988; Newcomb & Felix-Ortiz, 1992;).
Gilvarry (2000) listed several of the pre-eminent protective factors in the adolescent substance abuse literature: positive temperament; family environment supportive to the youth; functional, caring relationship with at least one adult; and an external support system that values and rewards pro-social values. Fergusson, et al. (1996) also found a series of protective factors including high intelligence, non-engagement in novelty-seeking behaviour, as well as the absence of friendships with antisocial peers.
Unfortunately, none of the studies examined in the present review explored protective factors and their role in providing effective treatment to a young offender population. The impact of protective factors for both the prediction and treatment of criminal behaviour which is tied to substance abuse has several obvious implications. For example, treatment programs could be built around these strength factors to enhance pre-existing positive conditions in the lives of the young offender. This approach has been adopted quite successfully in the family intervention literature with Functional Family Therapy (Alexander & Parsons, 1973; Alexander, Pugh, Parsons, & Sexton, 2000; Alexander, Sexton, & Robbins, 2000), an approach that has received strong empirical support regarding its therapeutic potential with young offender populations (Alexander & Parsons, 1973; Klein, Alexander, & Parsons, 1977; Barton, Alexander, Waldron, Turner, & Warburton, 1985; Gordon, Graves, & Arbuthnot, 1995). Therefore, considerable resources should be garnered in the future to explore this topic area in substance abuse treatment for young offenders.
A major problem that has plagued the field of substance abuse treatment is the high dropout rates (Henggeler, Pickrel, Brondino, & Crouch, 1996; Hiller et al., 1999a), a concern that has been noted in the non-offender treatment literature as well (Dobkin et al., 1998). This problem is a major consideration for program administrators since individuals who drop out of treatment are essentially wasting valuable and scarce program resources as the costs expended during intake and initial treatment are not recovered through reducing problematic client behaviours such as recidivism and/or substance use/abuse (Hiller et al., 1999a). Several variables associated with program attrition were identified in a recent study by Hiller et al. (1999a) in a sample of adult probationers. These factors were unemployment and high levels of depression, anxiety, and hostility. As discussed previously, psychopathology is also a key client variable related to program attrition.
Despite these well-documented difficulties in retaining program clients in substance abuse treatment, Henggeler et al. (1996) reported that multisystemic therapy (MST) may be a very promising intervention to avoid this crucial breakdown in service delivery. More specifically, the results of their study found that when exploring the services received by a sample of over 100 adolescents randomly referred to either traditional community services or MST, 98% of those in the MST condition received and completed a full course of appropriate treatment, compared to only 22% for those receiving alternate services.
The authors noted that the hallmark of success achieved by the MST approach in terms of significantly reducing program attrition may result from its reliance on strategies lauded by other experts as being critical to maximizing client retention in treatment (Stark, 1992; Szapocznik, Perez-Vida, Brickman, Foote, Santisteban, Hervis, & Kurtines, 1988). As summarized by Henggeler and his colleagues (1996), the key strengths of MST in this regard are:
- program therapists are always available;
- program team is fully responsible for treatment involvement of clients and subsequent achievement of program goals;
- the treatment program is developed from a strength-perspective with goals determined almost exclusively by the family members; and,
- program services are specifically tailored to meet the many dynamic needs of the clients.
Despite these promising findings for the effectiveness of MST programs in reducing client attrition, more work needs to be done in this area. For example, primary research within young offender populations should focus on what types of clients drop out from programs and their reasons for doing so. In addition, it may be useful to apply some of the program strengths identified by Henggeler and his colleagues to other forms of substance abuse or correctional programs offered to substance abusers to determine whether they have an equally positive impact in terms of preventing program drop-outs.
Given the importance of program attrition to the field of substance abuse treatment, researchers should devote considerable energy to uncovering those factors that are predictive of this critical negative treatment outcome. Some intuitively appealing variables that may be expected to be reasonably linked with client attrition, but require further empirical validation, include the satisfaction of the client with the program (Hiller, Knight, & Simpson, 1999b), client expectations of the treatment process (McCorkel, Harrison, & Inciardi, 1998) and the quality of the relationship between the counsellor and the client (Broome, Knight, Hiller, & Simpson, 1996; Broome, Knight, Knight, Hiller, & Simpson, 1997).
Previous research exploring the effectiveness of interventions for both offender (Dowden, 1998; Dowden & Andrews, 1999b; Latimer, 2001) and non-offender populations (Prendergast et al., 2000) has found that the involvement of the evaluator in the development and delivery of the treatment program has a significant effect on the results reported. More specifically, programs evaluated by an individual who was either directly or indirectly involved in some aspect of the program report stronger programmatic effects than those that did not.
Two alternate explanations have been proposed to explain this finding. The first is that evaluators who are involved in service delivery are much more likely to follow treatment protocols, to ensure staff are specifically trained, and closely monitor program structure and content to ensure it is delivered as intended. Put more succinctly, an involved evaluator will concentrate on program integrity issues (Dowden & Andrews, 1999a; Lipsey, 1995; Prendergast et al., 2000). An alternate hypothesis is that an involved evaluator is biased as they are "looking" for positive programmatic outcomes and so are more likely to present a more favourable impression of the results (Lipsey, 1995; Prendergast et al., 2000). Unfortunately, the literature to date has not provided a clear-cut answer to this question and designing a valid empirical test of this issue would be quite difficult.
As mentioned previously, substance abuse by adolescents tends to lead to many negative problem behaviours and outcomes, not necessarily limited to delinquency. An especially salient concern with this population is HIV/AIDS as the available data suggests a definite association between substance use and risk of sexually transmitted disease (Gilvarry, 2000). This relationship has also been documented in the criminal justice literature as well - research has consistently found that offenders are much more likely to test positive for HIV/AIDS than the general population (Collica, 2002; Hammett, Harmon, & Maruschak, 1999). This problem is even more intensified for female offenders as their rates of HIV within the criminal justice system exceed those of men, the only population in which females are more disproportionately affected (Anderson, Rosay, & Suam, 2002). The extremely high level of HIV/AIDS cases in correctional settings and the risks these individuals pose to each other, as well as the community at large, has prompted researchers to strenuously argue for the comprehensive targeting of this issue through intensive programming in prison (Hammett et al., 1999; Keeton & Swanson, 1998).
The issue of HIV/AIDS transmission for substance abusing offenders is critical when one considers the risky behaviours they engage in both inside and outside a correctional setting. For example, past research has found that inmates are more likely to test positive for HIV infection if they have been charged with a drug offence (Cotton-Oldenburg, Martin, Jordan, Sadowski, & Kupper, 1997; Hammett et al., 1999) or if they were injection drug users (Harrison, Butzkin, Inciardi, & Martin, 1998). The importance of addressing this need in youthful offenders is emphasized even further when one considers adolescent drug users report higher HIV risk behaviours compared to their adult counterparts (Battjes, Leukefield, & Pickens, 1992; Nelson, Vlahov, Solomo, Cohn, & Munoz, 1995). More alarmingly, there is evidence that some marginalized groups, such as street youth, may be particularly prone to engage in elevated levels of risky behaviour in this regard.
Given the strong relationship between substance abuse and criminal behaviour noted in previous research and the negative living conditions surrounding these youth, concerns about HIV/AIDS transmission should be viewed as even more critical. One potentially valuable intervention strategy in this area is peer-based HIV/AIDS treatment programs as they offer many advantages to both the offender as well as the correctional institution. For example, the high level of trust between offenders and their generally shared backgrounds may motivate program clients to attend more closely to program content. Furthermore peer counsellors are more available to the offenders given their constant presence in the unit. Peer-led groups would also have the advantage that the facilitator would be much more aware of the HIV/AIDS risk behaviours that are currently occurring within that institution and could use this knowledge to enhance the relevance of the program to the clients. Finally, from a more pragmatic perspective, these types of programs would be quite cost-effective (Hammett et al., 1999).
Alcoholics Anonymous (AA) views alcoholism as an incurable disease that must be coped with by the individual (McNeece et al., 2001). Based on this perspective, AA promotes an abstinence-based model for treating substance abuse. Other 12-step programs, such as Narcotics Anonymous, have been derived from AA, and essentially follow the same conceptual framework.
Despite their popularity, there is a dearth of research exploring their effectiveness (McNeece et al., 2001). One of the few evaluation studies that examined this approach (Alford, Koehler, & Leonard, 1991) reported the program only benefited adolescents who grasped and accepted the principles of AA, but a couple of caveats should be noted regarding this finding. First, a strong methodological limitation of this study was that a comparison group was not used so there was no way to track how another similar group of untreated offenders would fare on these outcomes. Furthermore, this study was conducted on a sample of non-criminal adolescents and therefore the findings may not generalize to an offender population.
Very preliminary data regarding the effectiveness of 12-step self-help programs to young offender populations was reported in the meta-analysis of Dowden et al. (in preparation). More specifically, the findings indicated that programs that incorporated self-help elements into their overall programmatic strategy yielded an increase in recidivism in the treatment as opposed to comparison group. However, the small number of effect sizes contributing to this result suggests that it should be interpreted with caution.
The above results suggest that much more work needs to be done in exploring the effectiveness of self-help programs for both offender and non-offender groups of substance-abusing adolescents. However, it should be noted that the preliminary evidence is not very promising. At the very least, if program administrators want to offer these types of services to young offenders, they must ensure that other forms of intervention are incorporated into the overall treatment plan.
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