An Evaluation of Treatment in the Maine Adult Drug Courts



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Table 20 includes the bivariate results predicting group membership from the psychological and social function scales, program attitude scales and the perception of legal pressure. Many of these scales distinguished the graduated from expelled group. Offenders who were expelled reported higher levels of negative functioning including higher levels of hostility, risk taking and anxiety. They also reported lower levels of treatment readiness, self-esteem, social conformity, social support, personal progress and therapeutic engagement. Offenders who were expelled also had lower scale values for program related measures including negative attitudes toward program staff, counselor competence, counselor rapport and group trust.

Some of these same factors also distinguished the active vs. graduated group membership. Active offenders reported higher levels of anxiety, less social conformity, social support and personal progress than those that graduated. Like the expelled group, they also reported lower scale values for program measures including therapeutic engagement, program staff, counselor rapport and competence and group trust than the graduated group. Active offenders additionally reported significantly lower levels of peer support and treatment services than the graduated group. None of the measures distinguished the active from the expelled group.

Attitudes toward the drug court program clearly distinguish the graduated group from both the expelled and active groups. Those that graduated viewed program components much more favorably than expelled and active groups. Psychological and social function scales also significantly distinguish the graduated from the expelled groups, and offer some distinction between the graduated and active groups. None of the scales differentiated the expelled from the active groups which further bolsters the importance that it is the use of sanctions that separates the expelled from the active group.



Multivariate Predictors of Status Outcome. From the bivariate results, the factors that significantly distinguished the graduated, active and expelled groups were considered for the multivariate model. Since there was little evidence of a distinction between the expelled and active group based on factors, we combined the active and expelled groups together. The outcome measure for this analysis was coded 1 if the offender graduated and 0 if they were expelled or active. Thus our outcome measure is based on a measure of success rather than failure in completing the drug court program.

Using the factors demonstrating significance in the bivariate analysis as independent variables (see Tables 21), we conducted a multivariate logistic regression analysis to determine the unique influence of each on whether or not an offender graduated. We began with a consideration of the background information on each offender. We included as independent variables whether or not the offender had a partner at the time of drug court admission, if he or she was employed at the time of admission and the last year of education completed. The variables measuring prior arrests, drug arrests and convictions were highly correlated so each was entered separately (drug arrests is included in the table). The results are reported in the Model 1 columns of Table 21. The results show that having a partner and education were significant predictors of success in the drug court program. Employment was not a significant predictor and the use of control-oriented sanctions did not predict successful drug court completion. Prior drug arrests were also not a significant predictor of successful completion. To preserve the degrees of freedom, employment, drug arrests and control oriented sanctions were excluded from further analysis.

We then considered the variables measuring attitudes toward the program. A test for multi-collinearity revealed that many of the program indicators were highly correlated with each other. Of these indicators, therapeutic engagement was highly correlated (.6 or above) with all of the other relevant program indicators with the exception of treatment services (See Appendix D). Thus, therapeutic engagement was chosen to represent the offender’s attitudes toward the program and treatment readiness.

In Model 2 of Table 22, attitudes toward treatment services were entered first into the model predicting drug court outcome. The results indicate that those who have positive attitudes toward treatment services were more likely to graduate and this effect was significant after controlling for education and having a partner. In Model 3, therapeutic engagement was entered into the model along with treatment services, having a partner and education. The results indicated that those who score higher on the therapeutic engagement scale are more likely to graduate and this effect is significant when controlling for the other factors. Therapeutic engagement also appears to mediate the effect of treatment service on the likelihood of graduating since treatment effects are no longer significant.



A test for multi-collinearity among the psychological and social function scales revealed that many of the scales were highly correlated with each other (see Appendix D). Since the strength and direction of the correlations varied, we entered each into the model separately while controlling for having a partner, education and treatment services. Given that these variables were also highly correlated with therapeutic engagement, we excluded therapeutic engagement from Model 4. We entered scores for anxiety, hostility, self-esteem, risk-taking and social conformity separately. Only social conformity demonstrated significance (see Model 4). Those scoring higher on the social conformity scale were significantly more likely to graduate when controlling for treatment services, education and having a partner. Social conformity also mediated the impact of treatment services to the point of insignificance.


Table 22. Logistic Regression Results Predicting Successful Completion of Drug Court Program





Model 1

Model 2

Model 3

Model 4

Variable

B




Exp(B)

B




Exp(B)

B




Exp(B)

B




Exp(B)

Have Partner

1.126

*

3.084

1.47

**

4.2

1.37

*

3.9

1.45

**

4.2

Last Grade Completed

0.489

*

1.63

0.44

*

1.55

0.414

*

1.5

0.373

*

1.4

Employment at Admission

0.329




1.39




























Control Oriented Sanctions

-1.089




0.337




























Prior Drug Arrests

-1.01




0.904




























Treatment Services










0.07

*

1.068

0.046




1.04

0.049




1.05

Therapeutic Engagement



















0.066

*

1.07










Social Conformity




























0.081

*

1.09

Model Chi-square

16.9**

19.95**

23.3**

21.6**

p< .05* , p<.01**







































Discussion
This study was designed to examine the issues related to drug treatment within adult drug courts in Maine. A process and outcome studies of the Adult Drug Courts were the responsibility of Dr. Don Anspach of the University of Southern Maine. His team has been conducting these studies for the last several years to assist the drug courts in implementation issues and to assist the drug courts in learning about outcomes. The studies have generally found that the drug courts in Maine target populations with prior drug treatment experience and those that have not been successful in community supervision in the past—a population that tends to be more difficult. The process evaluations have found that the drug courts deal with a slightly smaller target population than desired in some courts, and that for the most part the drug court process is followed. Outcomes are similar to national outcomes for drug treatment courts where 56 percent successfully complete the program within an average of 414 day window (see Anspach and Ferguson, 2005). Recidivism rates are 23 percent after one year of termination from the drug treatment court which is low given the characteristics of the target population for these drug treatment courts.

Drug treatment within the drug court program is a critical component of the intervention. Unlike other jurisdictions, Maine has developed and implemented a comprehensive drug treatment program for drug court participants. DSAT meets the established standards of NADCP for a 12 month treatment intervention that is comprehensive. DSAT was designed to consist of three critical phases of the treatment process: 1) motivation; 2) intensive skill building and cognition building; and 3) stabilization. More importantly the DSAT process incorporates a number of components to move offenders along the continuum of care based on their own progress instead of an arbitrary timeline. The study of drug treatment within the drug court was designed to determine whether the investment in quality drug treatment services has served to advance the outcomes from the drug treatment court in Maine. While it would have been preferable to conduct an experimental design to address this question, the funding and study time period did not allow for this to occur. Instead a quasi-experimental design using pre-post measures was implemented to determine whether the offenders in the drug treatment court made any clinical progress towards recovery. And, to what degree did drug court actions (e.g. supervision, drug testing, sanctions, etc.) impact the ultimate outcomes from the drug treatment courts. The answers to these questions provide an important starting point for considering how best to provide drug treatment to drug offenders in a drug court finding, an important question that few address (see Anspach and Ferguson, 2002; Taxman and Bouffard, 2002; Taxman and Bouffard, 2005).

Overall the findings from this study of DSAT has served the state of Maine well. The design of the curriculum and the training of the counselors (with period quality reviews) have resulted in the treatment programming being well implemented. A review of nearly half of the available quality review tapes found that for the most part the counselors implemented the cognitive skills in the reviewed sessions. The skills for the most part were advancing, and that the counselors improved over time (for those that had multiple tests). The tapes revealed that there was a need for more emphasis on treatment format, time management, and using tools in the treatment sessions. That is the counselors have the techniques and understand the core components of the DSAT manualized treatment component, more emphasis however is needed in applying them in sessions and using the appropriate group management skills. It is apparent that the process to implement DSAT was thoughtful and focused on developing the skill sets of the counselors in these drug treatment courts—OSA had a separate contract with a treatment organizational to train the counselors in various sessions and to work on acquiring these tapes. All of these revealed an approach that appears to contribute to the quality of treatment sessions. This is an area that many states are struggling.

Another part of the study examined the treatment process and outcomes for 99 offenders that were drug treatment court participants during the period of time that we were conducting this study. These 99 offenders are similar to the census of 236 offenders that were in drug treatment court at the time of the study except that more female offenders agreed to participate in the study. Similar to the work by Anspach and Ferguson, the offenders that tended to be terminated early from the drug treatment court were those that were dual-diagnosis. The study sample included 44 percent that were active during the whole study period, 18 percent that were expelled, and 36 percent that graduated successfully. We were able to measure progress in treatment for the offenders, some for only 3 months and others for six months (depending on the length in treatment). Overall we found that offenders tended to improve clinically during their involvement in treatment, although as expected those that were expelled did not improve as much as the other offenders. We also found that offenders that reported a rapport with the counselors (were engaged in the therapy process) did well as well as those offenders that recognized the need to conform socially. These are both significant variables that can improve outcomes for offenders. High continuous scores on hostility and risk taking behaviors are good predictors of failure in drug treatment courts, and these tend to be offenders that make less clinical progress.

The research also found that the type of sanctions used in the drug court program may impact the outcomes from the program. Expelled offenders tended to have almost all control-oriented sanctions, even for program technical violations. Treatment oriented violations—more self help groups, changes of phase in treatment, individual counseling, etc.—were not used for the expelled offenders while they were used for those in the active and/or graduated category. The small sample sizes do not allow us to conclude that control oriented sanctions contributed to negative outcomes, the bivariate relationships and significance level lead us to believe that the nature of the drug treatment court services may affect the ultimate outcomes. That is, for the offenders that are less likely to be engaged in the treatment sanctions and/or those that engage in high risk or are hostile, treatment-oriented sanctions may provide a remedy to facilitate the offender’s commitment to the goals of the drug court program. But, the control sanctions do not seem to further the engagement to the goals of the drug treatment court. A need exists to further explore these issues to determine how best to use the drug court program for these higher risk offenders that are more likely to fail.

Conclusion

Quality drug treatment services has been raised as a national issue regarding the need to ensure that the tax dollars are well spent and achieve the greatest outcomes. Many states have struggled with the concerns that drug treatment services overall may not achieve the desired outcomes, and that much of the issues have to do with the quality of services provided and the qualifications of treatment staff (Lamb, Greenlick, McCarty, 1998). The state of Maine in their drug treatment courts has taken a strategy that is considered desirable but few achieve—to develop a curriculum that is based upon sound principles of therapy, to train and advance the skills of the counselors that deliver the services, to evaluate the implementation and provide periodic feedback to improve outcomes, to include researchers in the team to provide objective feedback to the team regarding progress and components that should improve outcomes, and to address issues such as retention and screening tools as they occur. This evaluation study has shown that such a strategy can advance the delivery of treatment services.



The challenges before the state of Maine are the integration of treatment within the drug court setting. While the graduation rate overall is respectable (56 percent per Anspach and Ferguson, 2005), great strides need to be devoted to the 44 percent that do not graduate. The results from this study would suggest that the non-graduates are more likely to be the more difficult offenders with multiple needs (e.g., dual diagnosis, employment issues, hostile, higher levels of risk-taking behavior, etc.). And, the actions of the drug treatment court may need to be more attuned to the factors that can engage these offenders in a therapeutic process. The drug treatment court, as part of an overall strategy for advancing drug treatment and court practices, may desire to consider some of the following:

  • Educate the judiciary on engagement and cognitive behavioral strategies for offenders that tend to be high risk and hostile, and those that appear to be less engaged in the treatment process;

  • Educate the judiciary on the use of treatment oriented sanctions to shape offender behavior as part of the natural continuum of responses to negative offender behavior and advance the use of treatment related rewards to reinforce positive behaviors

  • Advance the use of the judiciary (as is the case in a few drug courts that we observed) to have informal sessions with offenders to discuss treatment and the value of the treatment processes as well as the drug treatment court; and,

  • Use different assessment tools to determine offenders that are less engaged in treatment, less committed to conformity, more high risk takers, and more likely to be hostile.

A few minor adjustments should assist with further integrating the drug treatment services into the fabric of the drug court. Maine has an excellent start with the DSAT curriculum, and these additional components may serve to continue the progress.

REFERENCES
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Appendix A



Frequency Tables



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