An Evaluation of Treatment in the Maine Adult Drug Courts



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Table of Contents




Section Page

Executive Summary ii-iv

Introduction 1

A. DSAT Tape Review 8


    1. Procedures and Materials 9

    2. Results 11

B. DSAT Study of 99 Offenders 19

a. Data Sources 20

b. Sample 21

c. Characteristics of Study Population 22

d. Generalizability of the DSAT Study Participants 23

e. Offender Progress Through the Maine Drug Court 24



  1. Impact of Drug Court on Psychosocial Functioning 30

of the Offender

g. Conclusion 41

References 43


Tables



Table Page

1. Session Phase Description 9

2. Description of Observational Categories 10

3. Treatment Format and Miscellaneous Treatment Tools 13

4. Relapse Prevention and Cognitive-Behavioral Treatment 15

5. Treatment Readiness and Contingencies 16

6. 12-Steps Programming, Education, and Community Management 17

7. Overall Average Range 18

8. Overall Reliability of Item Categories 19

9. Distribution of the Sample in the Study Across Drug Court 22

10. Status of the Completion of the DSAT Study 23

11A. Treatment Phase at the Time of the Entrance into the Study 24

11B. Length of Time in Each Phase of the DSAT Treatment Model 25

12. Length of Stay in Each Phase by Status at End of Study 25

13. Types of Violations 26

14. Type of Sanctions by Specific Categories 27

15. Type of Sanctions Given 27

16. Sanction Orientation by Status in the Drug Court Program 28

17. Analysis of Variance Violations by Status 29

18. Mean Number of Violations by Status 30

19. T-Test Comparisons of Drug Court Progress 32


  1. Bivarite Multinomial Logistic Regression Results Predicting 34

Status at End of Study-Administrative Variables

  1. Bivariate Multinomial Logistic Regression Results Predicting 35

Status at End of Study

  1. Logistic Regression Results Predicting Successful Completion 38

of Drug Court Program
The most profound example of an innovation in the substance abuse service delivery systems for offenders is the drug treatment court developed in 1989 in Miami, Florida. The court was viewed as the vehicle to bring the conflicting models of punishment and rehabilitation into a setting where the two philosophies could be integrated, instead of relying upon disparate programmatic components of treatment, drug testing, supervision/oversight, and compliance management (Taxman and Bouffard, 2002b; Goldkamp, White & Robinson, 2001; Anspach and Ferguson, 2002). The drug court model has as its rationale the reduction of drug use and related criminal behavior through the primary interventions of treatment and the judicial oversight (Belenko, 1999; 2001; Taxman & Bouffard, 2002b; Cooper, 2001; Goldkamp, White, & Robinson, 2001).

The drug court concept, as implemented in a variety of settings, provides the opportunity to explore how treatment is integrated into the drug court setting. Few drug court studies have examined the use of treatment services and the clinical progress that can occur as a result of the provision of drug treatment, as well as the impact of the drug court processes (e.g. status hearings and sanctions) on program outcomes (e.g. graduation, arrests, etc.). In other words, how are drug treatment services provided within the framework of the drug court? Do offenders make progress towards prosocial skills during the provision of treatment services? The available literature on drug treatment courts does not address these questions. Nor does it demonstrate how the drug treatment court can reinforce the goal of providing drug treatment: to reduce the recidivism of drug involved offenders by changing their drug using habits.



Drug Treatment Courts: The State of Knowledge


In the last decade drug court programs have thrived and grew to a nationwide phenomenon with over 1200 courts (Huddleston, Freeman-Wilson, & Boone, 2004), yet studies of drug courts have not occurred at the same pace. Most scholars admit that the quality of the studies, and the limited number of studies on drug treatment courts, undermines the confidence that can be given to the generally accepted positive findings about the drug treatment court. As observed by Goldkamp, White & Robinson (2001):

“The findings appear to show a dramatic and consistent drug court crime reduction effect, with drug court graduates generally showing substantially lower rearrest rates…from entry than nongraduates. As popular as these kinds of analyses may be among advocates seeking to declare the efficacy of drug courts, they are biased in the direction of showing positive results, and as such, are highly misleading. Basically, the much-heralded findings show that the successes succeed and the failures fail (2001:32).

Recent studies of drug treatment courts have started to explore the issues of the provision of treatment services. Several major studies have been conducted that employ sound research methods to explore the efficacy of drug courts, and to measure the services delivered to offenders (Harrell, Cavanaugh & Roman, 1998; Goldkamp, et al., 2001; Peters & Murrin, 1998; Gottfredson, Najaka, & Kearley, 2002; Anspach & Ferguson, 2002). In each study, the percentage of drug court clients actually participating in treatment services per sè varied considerably from 35 to 80 percent. And, the actual length of time spent in treatment (as opposed to the intended length of stay, which is generally 12 or more months) for clients in these programs also varied from under 30 days to over two years. The general finding appears to be that the longer the period of time in treatment, the greater the likelihood that the offender will graduate from drug court. And, more importantly, participation in drug treatment services, not necessarily just the drug court, reduces the likelihood of rearrest. Banks and Gottfredson (2003) found that 40 percent of the drug court offenders that participated in treatment were rearrested within a two-year window as compared to slightly over 80 percent of the drug treatment court offenders that did not participate in treatment1. Goldkamp, White and Robinson (2001) found that the more treatment sessions participated in, or the greater the percentage of time in treatment during the drug court program, the greater the reduction in rearrests. The same is true for the four-site study conducted by Anspach and Ferguson (2002) that found treatment participation is a critical variable affecting the graduation rates from these drug courts.

Taxman and Bouffard (2002a), in their secondary review of the data from a survey of 212 drug courts conducted by the Center for Substance Abuse Treatment (CSAT), assess the disjuncture between the delivery of treatment services and drug court operations. In key areas, the drug court respondents highlighted the lack of policy and procedures that support the drug court’s mission of providing treatment services for offenders. For example, drug courts tended to target eligibility for drug court based on the offense and criminal history, with less apparent focus on the type or severity of their substance abusing behavior. Nearly half (49%) of the drug courts reported that eligibility screening is conducted by non-clinical staff (e.g., probation officers). While this is appropriate in terms of screening for legal criteria, these staff may not have sufficient training and experience to conduct appropriate clinical assessment, which often follows legal screening of cases. Again, legal eligibility is generally based on legal considerations not substance abuse dependency. In relation to the clinical assessment phases, nearly 60 percent of the drug treatment courts reported that they excluded offenders from participation who were “not motivated for treatment”, yet one of the strengths of the drug court model is its ability to use the criminal justice system to leverage offenders into treatment who may not otherwise be motivated to tackle their drug use and its associated other problems. Half of the drug courts reported not having any formal (e.g., written) clinical placement criteria to determine what type of treatment services the offender should receive.

While these varied policies and procedures may be effective at ensuring individualized assessment and placement, the potential exists that they may also indicate areas in which additional policy and practical coordination between treatment and court systems is needed to streamline and solidify the processing of cases so that various responsibilities are not overlooked by one agency or another. As an additional example of a service area where improved coordination of activities may be merited, this CSAT report revealed that when case management services were provided, these services were infrequently provided by the drug treatment court itself (24% reported that the drug court coordinator provided such services), instead of being delegated to the treatment provider (26%) or a probation official outside the court (24%). According to these survey results, many of the courts also have more than one agency conducting drug tests (e.g., treatment providers, probation, etc.) and often the results were not shared. While drug courts are designed to integrate services across systems, these findings suggest that there are still several areas that may benefit from improvements in terms of coordination and communication between the court and treatment systems.

To date, research on the “black box” of drug courts’ actual intervention components is limited, particularly regarding the utilization of drug treatment services provided within the context of drug courts. The findings from the few well-designed studies on drug courts (Gottfredson, Najaka, & Keareley, 2002; Goldkamp, White, & Robinson, 2001) confirm that there is variation in the delivery of key functional components of drug courts—treatment, testing, and sanctions. One of the more informative studies of the delivery and effectiveness of treatment within the drug court was conducted by Gottfredson and her colleagues (2002). In particular, this study found that those who received drug court services, but no substance abuse treatment, did no better in terms of post-program recidivism than did those who were not in the drug court at all. As such, while the court and other criminal justice system components are essential in making sure that individuals go to treatment, the “active ingredient” (borrowing from a medical analogy) appears to be the participation in appropriate substance abuse treatment, as those who received testing and supervision alone showed no improvements in recidivism, despite the suggestion of critics such as Kleiman (2001) that treatment was not necessary. Indeed the combination of these systems is likely what makes the model effective, however that is not to say that effective persuasion (the court processes) would be all that effective if the treatment that is received is not of good quality (anymore than quality treatment can be effective if people do not participate in it, as has been the problem prior to the development of the drug court model). Having at least the suggestion emerging in the literature that treatment is a central effective component of the drug court model, the following study explores some of the issues related to the delivery of drug treatment within a drug court setting and then presents several fundamental issues for drug courts to consider in terms of the more thorough integration of these various services within the drug court program.



Drug Treatment Courts in Maine
The state of Maine has been an avid user of the drug treatment court concept. The state administers a variety of drug courts, but the subject of this study are the six adult drug treatment courts. The funding for the drug treatment and case managers in the drug treatment courts are provided by the Office of Substance Abuse Services (OSA). The courts provide the funding for the judiciary and the status hearings. Drug courts have had a premier position in the state for the last five years, and the OSA has funded process evaluations of the different adult and juvenile drug courts consistently. Dr. Donald Anspach and Mr. Andrew Ferguson from the University of Southern Maine have served as the evaluators and have worked with the drug treatment courts during their developmental and implementation time period (see http://www.maine.gov/dhhs/bds/osa/cj/adtc.htm for copy of the most recent study findings.)

Recognizing the importance of the treatment provided in the drug courts, the Office of Substance Abuse Services developed a thorough manualized treatment curriculum for the drug courts, and for all offender populations. OSA contracted with a firm that develops treatment programs and curriculums to create the Differential Substance Abuse Treatment (DSAT) curriculum and processes—this is a comprehensive system that integrates all of the components of an evidence-based practice in treatment services to offenders. The DSAT treatment process has four stages: 1) orientation and motivation enhancement (MET) (open ended for 4 to 10 weeks). In this first phase the focus is on treatment readiness to improve retention. The number of sessions in the MET phase that a client is required to attend varies by the needs of the client and is determined after a comprehensive clinical assessment. From here, the clients enter either the Pre-treatment group phase (to continue to develop treatment receptivity and basic treatment skills) or directly enter the next phase; 2) cognitive and behavioral skill development (intensive services) for 10 to 15 weeks. The curriculum includes sessions on: Education, Decisional Balance, Looking at Addiction, Personal Goal Setting, Risk Strategies, Coping by Thinking, Interpersonal Problem Solving, Support, Assertiveness Skills, Relapse Prevention, Leisure Skills, Job Skills, Communication/Social Skills, Coping with Emotions, and Relapse Prevention; 3) skill modeling and maintenance for 12 to 24 weeks. In addition, the offender in the drug court program can participate in individual sessions and aftercare that includes other community related services such as mental health, service, housing, and so on. The DSAT treatment curriculums are well-developed treatment programs with each section having specific goals and objectives for each session, curriculum, skill development and practice exercises, and assessment of the skills gained. The program includes several treatment phases and types of meetings. The groups are to be run in closed session (all offenders enter at the same time) to ensure that there is a cohesive group therapy session built on trust and achievement of core skills among the offenders. Some of the sessions are designed for different gender and cultural issues with services to address the multiple needs of the offender community in treatment. Dr. Anspach commissioned two external reviewers of the curriculum with both confirming that the manuals were well developed and integrated core concepts of cognitive behavioral therapy for offenders.

Most importantly, OSA invested in on-going skill enhancement of the counselors that encourages counselors to learn the curriculums, advance in the application of the curriculum, and receive feedback on the development of their own clinical skills. All of this contributes to the certification process for counselors. That is, the DSAT process includes a component of quality control to ensure that the counselors are familiar with the curriculum and display expertise in the cognitive behavioral therapy methodology. While infrequently recognized as a core component of the DSAT program, this process provides a methodology to ensure that the therapy provided to the offenders is at the highest quality available. And, it develops the skill sets of the counselor community in Maine. Videotape of group therapy sessions occur on a frequent basis, and then provide an avenue for the counselor to be rated on their skill sets. This process will allow the counselors to advance their skills in core areas that need attention.

The DSAT process also includes the use of screening, assessment, and treatment placement criteria to determine whether an offender will benefit from the DSAT community based treatment model. The screening is an invalidated tool that merely identifies a potential substance abuse problem. The Addiction Severity Index (ASI) is used in conjunction with a modified American Society of Addictive Medicine (ASAM) as criteria for treatment placement. However, the drug court process itself uses legal charge first to determine eligibility for involvement in the drug court. The substance abuse assessment becomes secondary, which is common for many drug court systems (see Anspach and Ferguson, 2002 for a discussion of this point).



Drug Treatment: Can Offenders Progress?

OSA requested that Dr. Anspach conduct a special evaluation of the DSAT drug treatment curriculum as part of the evaluation of the drug treatment courts. Dr. Anspach entered into a subcontract with Dr. Faye S. Taxman (then with the University of Maryland) to conduct this study. The purpose of this substudy was to examine whether offenders made any clinical progress in drug treatment during their participation in drug court, and the impact of the drug court processes on offender outcomes. The study was focused on the drug treatment per se, and not the drug court processes.

The study involved two components: 1) a review of a subset of clinical video tapes of DSAT; and 2) a review of the progress of 99 offenders that volunteered to be interviewed periodically during the study period (around 15 months).

A. Dsat Tape Review

A sample of video taped treatment sessions were taken from an community DSAT agency in Maine. (In practice, OSA has all agencies receive feedback on their sessions either through videotape or direct observations. In this study, we only used a sample of the tapes.) Three different counselors were asked to video tape their treatment sessions with their group of clientele. Although approximately 25 tapes were recorded, resource constraints limited the number of tapes that could be observed to ten. These ten were randomly selected to be observed and coded using the observational tool. The tapes that were selected varied in their treatment phase, specific session content and counselor. Each tape is approximately two hours in duration. Table 1 presents information related to the ten observed tapes, including the treatment phase for each session, the stated purpose of each session (from program manuals), and the observers who were trained in the observational skills. (See Bouffard and Taxman for a description of the methodology.)


Table 1. Session Phase and Description

Tape

Phase/Session Label

Program Description*

Observers’ Descriptions

1

MET 3:

Drugs on Trial



Motivation Building

Motivation; pros and cons of substance use

2

Intensive 6:

Coping by Thinking



Thinking influencing emotions and behavior; productive and destructive thinking

Linking thoughts and actions; understanding cognitive processes or feelings; creating new ways of thinking

3

Intensive 15: Relapse Prevention

Relapse Prevention

Relapse prevention

4

MET:

Drugs on trial



Motivation Building

Motivation; pros and cons of substance use

5

Intensive 6:

Coping by thinking



Thinking influencing emotions and behavior; productive and destructive thinking

Coping by thinking, destructive & constructive thoughts; rethinking patterns

6

Intensive 3: Looking at Addiction

Why and how people become addicted

Understanding addiction; desired and undesired consequences of drugs/alcohol

7

Intensive 9: Assertiveness

Ability to act assertive in high risk situations

Assertiveness

8

Intensive 13: Communication/ Social Skills

How to communicate better with people

Communication and social skills

9

Intensive 14: Coping with Emotions

How to cope with emotional challenges (anger)

Emotional management, identifying and coping with emotions

10

Intensive 15: Relapse Prevention

Relapse prevention

Relapse/trigger prevention

* Hubbard, D.J. (2002)
Procedures and Materials

This section describes the data collection methods and observational tool used to assess the therapeutic integrity of this program. In general, the current version of the observational tool measures the amount of time spent on various treatment topics and activities by having trained observers record, in five-minute increments, the amount of time dedicated to these various treatment items, as they observe these activities. Items on the observational tool generally represent treatment components representing the cognitive-behavioral perspective, 12-steps/ Alcoholics Anonymous approaches, therapeutic community concepts, educational topics (e.g. parenting skills, anger management), and community management items (e.g., introducing new clients, check-ins), among others (see Table 2). After observing a given meeting, the researchers also complete summary ratings which describe the treatment meeting more generally, for instance in terms of the level of involvement of the clients and the primary format used in the meeting (e.g., staff lecture, group discussion).

Observers were instructed to record only the primary treatment activity and format taking place at any given time. In other words, if the treatment clients were observed discussing their current emotional processes regarding their family members, the observers coded that as a discussion of “current emotional processes” rather than as a discussion of “family issues”, since the primary purpose of the treatment activity was to uncover the emotional processes, not to deal with lingering family issues. While this means that observer’s ratings were precise and avoided potentially confounding overlap of observed items, it also means that they lack some degree of completeness, as only the primary topic being reviewed was coded.



Table 2. Description of Observational Categories

Observational Category

Description and “Sample Items”

Treatment Group Management

Rule setting, announcements; “Check-In”, “Introduce new clients”, “Room Set-up”

Cognitive-Behavioral Treatment

Examine and develop new cognitive, emotional, and social skills; “Existing Cognitive Processes”, “Trigger Analysis”, “Relapse Prevention”

12 Steps/ TC

Alcoholics Anonymous traditions, therapeutic community components; “Moral Inventory”, “Reliance on a Higher Power”, “Confrontation by Peers”

Safety/ Self-Exploration

Issues related to a safe group environment, exploration of past issues; “Psychological Safety”, “Past Family Experiences”

Education/ Aftercare

Delivery of educational or after care planning services; “Vocational Education”, “Parenting Skills”, “After Care Treatment Planning”

This observational tool has proven useful in more fully documenting the specific content of substance abuse treatment services offered to participants in both jail-based drug treatment and in adult drug court treatment services. As previously discussed, the main point of emphasis here is on reliability and validity of the observational tool devised to measure the amount of time spent on various treatment topics and activities. Three observers were trained in the use of the observational tool. Definitions of each item of the tool were reviewed and discussed at length. In order to determine inter-rater reliability, each observer separately watched each of the ten tapes and recorded their own observations resulting in three observations for each tape.



Validity of the tool will be discussed in terms of the comparison of these observed classifications with the stated approach used in the programs, though discrepancy between classifications based on the observations and the stated therapeutic approach of the program might also suggest that the program is not delivered with therapeutic integrity.
Results

Each of the tables in this section presents the range of time (in minutes) that each item was observed, across the three observers of each taped treatment session. For example, if Observer 1 rated 12 minutes of Staff-lead Discussion, Observer 2 rated 10 minutes and Observer 3 rated 13 minutes, the range (longest and shortest total time would be 10-13 minutes), while the difference in the amount of time rated for this item would be 3 minutes. Thus in interpreting the reliability of this observational process the smaller the value of the range, the more reliably the observers were able to rate or agree on the total amount that item was observed during each session. In addition, the average range is then calculated for each item (horizontally in the tables; as the mean range for that item in all 10 taped sessions, 0’s included) and for each taped meeting (vertically in the tables; as the mean range for all items within each meeting, 0’s included).

Treatment Format and Miscellaneous Treatment Tools. This section explores the type of treatment format most commonly used within each observational session and the type of tool, if any, used within the session (See Table 3). Most of the discrepancy between the observers’ ratings was in the item representing a Staff-lead discussion format. Most of this inconsistency occurred as a result of difficulties differentiating between what constituted ‘staff-lead discussion’ and other treatment formats such as ‘client-lead discussions’ or ‘writing exercises’. These conflicting observations are mainly due in part to the way that some of common treatment tools were employed in the program and a lack of precision in the definition of the “Staff-lead discussion” item. For example, if a counselor leading the group asked the clients to work on a group exercise (developing a written list of possible responses to a hypothetical scenario), there may be discrepancy in whether the observers recorded this as ‘staff-lead discussion’ or ‘writing exercises’. In this example, due to the fact that the staff was still essentially leading the discussion, one observer might code this format as Staff-lead discussion while another might focus on the fact that the clients were taking time to write an exercise thus coding the actions differently.

Table 3. Treatment Format and Miscellaneous Treatment Tools







Number of Sessions Observed










1

2

3

4

5

6

7

8

9

10

Mean

Treatment Format

Staff Presentation

0

0

0-8

(8)


0

0–6

(6)


0

0

0

0

0

1.4

Staff Lead Discussion

66-85

(19)


113-124

(11)


84-115

(31)


36-62

(26)


79-112

(33)


79-89

(10)


58-79

(21)


54-78

(24)


90-100

(10)


30-45

(15)


20

Client Presentation

0

0

0-16

(16)


0

0

0

0

0

0

0

1.6

Client Lead Discussion

0

0-17

(17)


0

0

0

0

0-22

(22)


0

0

0-15

(15)


5.4

Open Discussion

0-10

(10)


0

5-5

(0)


18-18

(0)


0

0

0

0-8

(8)


0

0

1.8

Miscellaneous Treatment Tools

Counselor Shares Personal Information

0

0

0

0

0-4

(4)


0-1

(1)


0

0

0-1

(1)


0

0.6

Writing Exercises

0-3

(3)


0-25

(25)


0-7

(7)


0

0

0

0-14

(14)


0

5-9

(4)


0

5.3

Other Homework

0-3

(3)


0-4

(4)


0

0

0

0-12

(12)


0

0-7

(7)


0

0-8

(8)


3.4

Video Tapes/

Movies


0

0

0

0

0

0

0

0

0

0

0

Ceremonies

0

0

0

0

0

0

0

0

0

0

0

Role Plays

0-11

(11)


0

0

0

0

0

20-30

(10)


12-20

(8)


10-17

(7)


0

3.6

Mean




4.18

5.18

5.64

2.36

3.91

2.09

6.09

4.27

2.0

3.45






Relapse Prevention and Cognitive-Behavioral Treatment. This section (see Table 4) examines the level of agreement in ratings among the three observers in relation to relapse prevention and cognitive-behavioral treatment (CBT) items. In general, there was relatively good agreement among the observers within this set of items, with most items showing no more than an average of five minutes discrepancy per meeting. In addition, all three raters agreed on 7 of 17 items that no amount of that item occurred in the taped meetings. On the other hand, some meetings were particularly more difficult to consistently code (taped meeting number 3 for instance). However, most of this discrepancy appears to have occurred due to difficulties in distinguishing between two aspects of relapse prevention (i.e., RP planning and trigger analysis). Thus, most of the source of disagreement within this meeting, seems to center on the inability to consistently decide whether what was being observed was best categorized as an attempt to increase clients’ awareness of the triggers of their relapse or as an attempt to plan how to respond to those triggers. In essence the observers agreed on the general nature of the intervention at hand, but not on the specific focus of the relapse prevention activity.
Table 4. Relapse Prevention and Cognitive-Behavioral Treatment




Number of Sessions Observed








1

2

3

4

5

6

7

8

9

10

Average

Relapse Prevention

Trigger Analysis/ Awareness

0

0-3

(3)


0-40

(40)


0

0

18-25

(7)


0

0

0

0

5.0

Relapse Prevention Planning

0

0


69-123

(54)


0-3

(3)


0

0

0

0

0

3845

(7)


6.4

Aftercare Treatment Planning

0

0

0

0

0

0

0

0

0

0

0

Aftercare Social Service Planning

0

0

0

0

0

0

0

0

0

0

0

Aftercare Support Planning

0

0

0

0-1

(1)


0

0

0

0

0

0

0.1

Cognitive- Behavioral Treatment

Link Feelings/ Thoughts Behaviors

0

35-50

(15)


0

0

16-48

(32)


0

0

0

0-5

(5)


0

5.2

Existing Attitudes/ Values

0

0

0

0-20

(20)


0

0-5

(5)


0

0

0-1

(1)


0

2.6

New Attitudes/ Values

0

0

0

0

0

0

0

0

0

0

0

Existing Cognitive Processes

0

39-39

(0)


0

0

22-55

(33)


0

0

0

3-5

(2)


0

3.5

New Cognitive Skills

0

27-55

(28)


0

0

35-49

(14)


0

0

0

0

0

4.2

Existing Emotional Processes

0

0-13

(13)


0

0

0-16

(16)


0-2

(2)


0

0

60-69

(9)


0

4.0

New Emotional Skills

0

0

0

0

0

0

0

0

12-22

(10)


0

1.0

Self Efficacy (self-esteem)

0

0

0

0

0

0

0

0

0

0

0

Structured Social Skills

0

0

0

0

0

0

0

0

0

0

0

Problem Solving/ Coping Skills

0


0

0


0

0

0


0

0

0-6

(6)


0

0.6

Daily Living Skills

0

0

0

0

0

0

0

0

0

0

0

Anger Management

0

0

0

0

0

0

0

0

0

0

0

Mean




0

3.47

5.53

1.41

5.59

0.82

0

0

1.94

0.41




Treatment Readiness and Contingencies. The following table examines the treatment readiness and contingencies used in the sessions observed. Each of the sessions are two hours in duration, so any item that has less than five minutes per item or meeting different is considered to be in agreement with the raters. For the most part the treatment providers used good skills to address treatment readiness issues and to do contingencies.

Table 5. Treatment Readiness and Contingencies







Number of Sessions Observed







1

2

3

4

5

6

7

8

9

10

Average

Treatment Readiness

Clinical Education

0-8

(8)


0-3

(3)


3-7

(4)


0

0-3

(3)


15-25

(10)


0-3

(3)


0-1

(1)


0-9

(9)


0

4.1

Motivation Building

65-81

(16)


0

0-1

(1)


42-60

(18)


0

0-3

(3)


0

0

0

0-3

(3)


4.1

Alternative Goals

0

0

0

0

0

0

0

0

0

0

0

Contingencies

Formal Sanctions

0

0

0

0

0

0

0

0

0

0

0

Rewards/ Positive Recognition

0

0

0

0

0

0

0

0

0

0

0

Confrontation by Counselor

0

0

0

0

0

0

0-1

(1)


0-1

(1)


0

0

0.2

Confrontation by Peers

0

0

0

0

0

0

0

0-1

(1)


0

0

0.1

Average

3.4

0.4

0.7

2.6

0.4

1.9

0.6

0.4

1.3

0.4





12-Steps Programming, Education and Community Management. None of the observers noted any of 12-steps programming or education items (see Table 6) as occurring in this sample of meetings. The only variation in the community management category was a small range of observed amount of time spent on rules, housekeeping, and/or announcements. In general then there was relatively consistent agreement among these observers that these types of treatment items were not occurring in the sample of meetings.

Table 6. 12-Steps Programming, Education, and Community Management







Number of Sessions Observed








1

2

3

4

5

6

7

8

9

10

Average

12-Steps Programming

Acceptance of Powerlessness

0

0

0

0

0

0

0

0

0

0

0

Spirituality/ Higher Power

0

0

0

0

0

0

0

0

0

0

0

Moral Inventory

0

0

0

0

0

0

0

0

0

0

0

Making Amends

0

0

0

0

0

0

0

0

0

0

0

Other 12-steps Traditions

0

0

0

0

0

0

0

0

0

0

0

Education

Parenting Skills

0

0

0

0

0

0

0

0

0

0

0

Academic Education

0

0

0

0

0

0

0

0

0

0

0

Vocational Education

0

0

0

0

0

0

0

0

0

0

0

Job Skills Training

0

0

0

0

0

0

0

0

0

0

0

Community Management

Introduce New Clients

0

0

0

0

0

0

0

0

0

0

0

Check-In

0

0

0

0

0

0

0

0

0

0

0

Rules/ Housekeeping/

Announcements



2-5

(3)


4-7

(3)


5-7

(2)


0

0-2

(2)


0-3

(3)


0

0-3

(3)


0-5

(5)


0

2.1

Community Building Activity

0

0

0

0

0

0

0

0

0

0

0

Physical Exercise/ Warm Up

0

0

0

0

0

0

0

0

0

0

0

Relaxation/ Visualization

0

0

0

0

0

0

0

0

0

0

0

Physical Safety in Group

0

0

0

0

0

0

0

0

0

0

0

Psychological Safety in Group

0

0

0

0

0

0

0

0

0

0

0


Summary of Observations. Table 7 presents the average disagreement among the 3 observers, across all item types by meeting. In general then, the observers were on average no more than 3 minutes apart from one another in their ratings of these several dozen treatment content/format items in this sample of ten videotaped meetings. Across all meetings and all items types these three observers were able to produce ratings of the amount of time spent on various topics that were only slightly more than 90 seconds different from one another.

Table 7. Overall Average Range



Number of Sessions Observed








1

2

3

4

5

6

7

8

9

10

Overall Total Average

Total Average

1.28

2.14

2.86

1.49

2.60

0.93

1.25

0.93

1.42

0.84

1.57

Table 8 presents results for the reliability of the observational tool, aggregated across item category. In general, the lowest level of reliability seems to have occurred among the Treatment Format items. This finding is likely due to the difficulties encountered in precisely capturing the nature of several specific treatment activities commonly used in this sample of meetings. In essence the difficulty centered on how to categorize in-class writing assignments and other forms of in-class, small group work that did not accurately fit the definition of “staff-lead discussion”. The next largest indicator of disagreement appears to have occurred within the Relapse Prevention and Cognitive-behavioral item category. As noted above, this disagreement generally occurred as a result of difficulties in consistently classifying relapse prevention activities as either initial “trigger analysis” or subsequent planning to prevent relapse based on the knowledge of these triggers. For the most part, however the disagreement occurred over which component of relapse prevention to code the activity as. In this case, then the disagreement is not between competing item types, but rather between which component of the overall activity type labeled “relapse prevention” to code. While examining the average range of observed time including zero’s in the calculation of the mean serves to reduce the appearance of any discrepancy in the observers’ ratings, information presented in Table 3 regarding the average discrepancy (among only those meetings/items where there was a discrepancy, meaning without zeros in the calculation) still shows relatively good levels of agreement across observers. Generally, these average differences among observers reveal less than 15 minutes of disagreement, again primarily in terms of treatment format items and relapse prevention items, both of which have been described above. Finally, as one additional way to assess the level of agreement among the three observers by item category, the third column in Table 8 includes the proportion of all items at all meetings in which all three observers rated the item as a zero. Across item categories, all three observers rated from 66% to 88% of the items as not occurring at all.



Table 8. Overall Reliability of Item Categories


Category Items

Mean

Mean without 0’s

Number of 0’s

Treatment Format and Miscellaneous Treatment Tools

3.92

11.65

73/110

(66.36%)


Relapse Prevention and Cognitive-Behavioral Treatment

1.92

14.17

147/170

(86.47%)


Treatment Readiness and Contingencies

1.21

5.31

54/70

(77.14%)


12-Steps, Education and Community Management

0.12

3.00

159/180

(88.33%)


Summary

1.57

8.53

433/530

(81.7%)



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