Appendix E
Linking Treatment to Punishment: An Evaluation of Drug Treatment in the Criminal Justice System

Jeanette Covington

Drug treatment takes place in a number of different modalities, including therapeutic communities, outpatient drug-free programs, chemical dependency programs, and methadone maintenance programs. The majority of clients who enter and leave these programs do so voluntarily (Substance Abuse Mental Health Services Administration, 1999). However, some clients are referred to these same programs by the criminal justice system and can therefore be punished or threatened with punishment if they fail to respond to treatment and abstain from drugs.

For example, court-based offender management programs, such as Treatment Alternatives to Street Crime and drug courts draw on populations of probationers and refer them to treatment programs in the community. Drug treatment in the criminal justice system takes place among populations of incarcerated prison inmates who are encouraged or required to seek treatment in prison. At least some of these prison-based treatment programs are affiliated with community-based after-care programs that allow inmates to continue therapy when they return to the community on parole. Hence, drug treatment programs in the criminal justice system can in part be distinguished from voluntary programs by the clients they serve. In short, drug treatment programs in the criminal justice system are distinct in that they recruit clients from what are referred to as “captive” populations of prisoners, parolees, or probationers and encourage or require those that they supervise to enter treatment in prison or in the community.



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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us Appendix E Linking Treatment to Punishment: An Evaluation of Drug Treatment in the Criminal Justice System Jeanette Covington Drug treatment takes place in a number of different modalities, including therapeutic communities, outpatient drug-free programs, chemical dependency programs, and methadone maintenance programs. The majority of clients who enter and leave these programs do so voluntarily (Substance Abuse Mental Health Services Administration, 1999). However, some clients are referred to these same programs by the criminal justice system and can therefore be punished or threatened with punishment if they fail to respond to treatment and abstain from drugs. For example, court-based offender management programs, such as Treatment Alternatives to Street Crime and drug courts draw on populations of probationers and refer them to treatment programs in the community. Drug treatment in the criminal justice system takes place among populations of incarcerated prison inmates who are encouraged or required to seek treatment in prison. At least some of these prison-based treatment programs are affiliated with community-based after-care programs that allow inmates to continue therapy when they return to the community on parole. Hence, drug treatment programs in the criminal justice system can in part be distinguished from voluntary programs by the clients they serve. In short, drug treatment programs in the criminal justice system are distinct in that they recruit clients from what are referred to as “captive” populations of prisoners, parolees, or probationers and encourage or require those that they supervise to enter treatment in prison or in the community.

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us Because treatment clients in criminal justice programs are recruited from these captive populations, they can be distinguished from voluntary treatment clients in that punishment or the threat of punishment is very much a part of any treatment they receive. Presumably, by linking treatment to punishment, criminal justice drug programs can make the consequences of continued drug use more costly for their clients and thereby deter them from continuing drug use once they complete the program. Indeed, it is widely asserted that by linking treatment to punishment or its threat, these programs have done at least as well as voluntary programs in terms of getting users off drugs (Hubbard et al., 1988, 1989). Not only do criminal justice system-supervised clients differ from voluntary clients because they face punishment or the constant threat of punishment, but they also differ in that system-based programs more narrowly define client success in terms of abstinence. Certainly abstinence is the ideal for programs that treat voluntary clients as well, but staff in these programs typically find that even their most promising graduates routinely relapse and return to treatment. A more significant problem for treatment staff offering therapy to voluntary patients is high dropout rates as many voluntary clients enter treatment, stay very briefly, and then leave without stopping their drug use. In fact, because their clients are voluntary, they cannot be forced to stay in treatment long enough for it to take effect, nor can they be stopped from leaving if they have not achieved abstinence. Yet in the view of some, a cycle of treatment-seeking followed by relapse and then more treatment-seeking is to be expected, because addiction is a chronic relapsing condition (O’Brien and McClellan, 1996). Thus, there is a presumption that some users will stop and restart their drug use many times before they are able to sustain abstinence. Because recovery after a single treatment episode is rare, therapists who treat voluntary clients often stress other, more modest goals along with abstinence. For example, voluntary clients may be deemed successful if they manage to sustain longer drug-free intervals after a single treatment episode, or if they manage to reestablish ties with nonusing significant others. In fact, both these changes can be important preliminary steps on the road to recovery. If drug addiction is indeed a chronic relapsing condition that requires multiple treatment episodes before rehabilitation can occur, then the abstinence orientation of criminal justice treatment programs may not be in keeping with the recovery process.1 Indeed, it might even be said that the 1   For the purposes of this paper, drug addiction is defined as a chronic relapsing condition. The author is not confident that drug addiction qualifies as a disease.

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us probationers, parolees, and prisoners who participate in criminal justice system treatment are being set up to fail because recovery after a single treatment episode is demanded of them. If they fail to sustain abstinence after they leave the program, then they risk additional punishment. In fact, by linking treatment to punishment, these programs risk having a countertherapeutic effect because they stigmatize the user. Drug users who participate in criminal justice treatment programs are stigmatized because their drug relapses can be punished with short stints in jail or longer stretches in prison. Since would-be employers may refuse to hire users with a record of incarcerations and law-abiding significant others may ostracize such users, punishing drug relapses in these ways may ultimately slow recovery. After all, securing stable employment and establishing ties to law-abiding significant others are crucial in the recovery process (Peters et al., 1999; Biernacki, 1986; Waldorf et al., 1991). Yet despite these concerns about the limits of criminal justice treatment programs in speeding the recovery process, there is a good deal of research on system-based programs that seems to suggest that they are effective in getting their clients to abstain after a single episode of treatment. Since any claims that system-based programs are effective depend on how these programs are evaluated, this appendix examines the evaluation research on treatment programs in the criminal justice system. Particular attention is paid to research on four programs: in-prison treatment, prison after-care programs, Treatment Alternatives to Street Crime (TASC), and drug courts. To determine if these programs are effective in bringing about client recovery in a single treatment episode requires some focus on how studies that evaluate these programs are designed. Hence the next section discusses the elements of an appropriate study design that will guide this review. GUIDELINES FOR EVALUATING SYSTEM-BASED DRUG TREATMENT To determine if treatment works or not requires that evaluations of treatment effectiveness be well designed. What follows is a list of the elements that contribute to a well-designed study. Controlling self-selection bias. Among other things, appropriate study designs allow researchers to separate treatment effects from other factors that might influence client outcomes. For example, clients may abstain from drug use after a treatment episode because the program was effective in changing them, or because they themselves are so committed to

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us getting off drugs that they persevere in demanding treatment programs, graduate, and abstain. Hence, clients who successfully abstain may succeed due to treatment effects, or they may be self-selected and succeed independent of treatment effects. Some researchers make an effort to control for this self-selection bias by randomly assigning subjects in their study to either a treatment group or a no-treatment control group. In this way, committed clients will end up in either the treatment group or the control group at random. Often study subjects in evaluation studies of system-based programs are randomly assigned to either a treatment group or a no-treatment control group from a waiting list. Studies based on comparisons between treatment and no-treatment control groups are important because they can demonstrate if treatment works better than no treatment at all. However, in some evaluation research on system-based treatment programs, clients are randomly assigned to two different types of treatment. This is considerably less desirable than a study design that creates a no-treatment control group, because comparisons between two different types of treatment can determine only if one treatment program works better than another; such study designs cannot establish whether treatment works better than no treatment at all. Other commonly used study designs in the evaluation research on system-based programs do not use random assignment at all. Instead they set up comparison groups that are matched to the treatment group on a few broadly defined demographic characteristics. Because these studies do not control for self-selection bias, it is often difficult to know how to interpret any findings that are based on such research. Controlling for a stake in conformity. Apart from a study design that controls for differences in client motivation, there is a need to control for other client characteristics that might influence outcomes, independent of treatment effects. For example, some clients fare better in treatment than others because they have more of a stake in conformity. In particular, clients who have steady jobs or are married tend to fare better in treatment than those who are not because these conventional roles give them some additional incentive to persevere in the difficult recovery process and eventually abstain from drugs (Peters et al., 1999; Biernacki, 1986; Waldorf et al., 1991). Consistent with this research, studies on general populations of drug users indicate that getting married or taking one’s first real job figures heavily in users’ natural desistance from drugs even without treatment or punishment (Bachman et al., 1997). Fortunately, client characteristics like marital status and employment status are external and easily measured and therefore can be controlled in evaluation studies. It is important that these individual characteristics be controlled in

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us order to determine how much client success is due to incumbency in these roles prior to treatment and how much is due to treatment program effects. However, it is not enough to simply isolate and control these effects for those who have them before treatment; they should also be controlled in posttreatment follow-ups. After all, some clients may abstain in the posttreatment period because they suddenly acquire a stake in conformity by getting married or beginning to work steadily and not simply due to any previous treatment effects. Use of credible outcome measures. Apart from controlling for clients’ internal commitments and external incentives to recover, it is also important that a study make use of credible outcome measures. Success in most system-based treatment programs is defined in terms of whether or not clients abstain from drugs after they leave treatment, and levels of client abstinence in the follow-up period are variously measured in terms of self-reports, rearrests or reincarceration for the resumption of drug use. Yet there may be reason to question whether these measures provide accurate estimates of drug relapse in the follow-up period. Regular and random urine testing in the follow-up period would seem to be the most accurate method for estimating what percentage of clients relapse. Identifying appropriate follow-up periods. Apart from the problem of identifying credible outcome measures, a related problem has to do with whether an appropriate follow-up period is selected for measuring client outcomes. Evaluations of drug treatment programs in the criminal justice system often make use of inappropriate follow-up periods, as they only follow clients in the short term, while they are on probation or parole. However criminal justice treatment programs have two components: the therapeutic component, which attempts to change or rehabilitate the client (e.g., counseling, therapeutic community) and the punitive component which attempts to make the client conform to the therapeutic regimen long enough to make needed changes. Hence, criminal justice clients can be said to have completed treatment only after both therapy and the risk of punishment have ended. This means that the appropriate follow-up period for programs that link treatment and punishment only begins after both the therapeutic and punitive components of treatment have ended. Probation and parole should not be used as follow-up periods because criminal justice clients are still in the punitive component of the treatment program. It is only after parole and probation, when all program interventions have ceased, that it is possible to tell if the combination of therapy and punishment have somehow changed clients so that they are able to sustain abstinence on their own in the long term. Linking retention to outcomes. In past research, when program participants have been able to sustain abstinence from drugs after they leave

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us treatment, longer stays in treatment have traditionally predicted these successful outcomes. There is a good deal of evidence that treatment programs in the criminal justice system have been highly effective in using punishment or the threat of punishment to induce their charges to stay in treatment long enough for it to take effect (Wexler et al., 1992; U.S. General Accounting Office, 1997; Belenko, 1998; Hubbard et al., 1988; Hubbard et al., 1989). Hence, evaluations of system-based treatment programs should go a step further and determine whether the longer retention of criminal justice treatment participants somehow translates into positive posttreatment outcomes. Identifying treatment components that promote recovery. Finally, some evaluation researchers have focused on teasing apart those components of treatment that work. For example, some treatment programs treat clients in several different stages. Prison treatment programs, in particular, are sometimes associated with after-care programs in the community. These multistage programs enable an inmate to begin recovery in the prison treatment program and continue the recovery process in a community-based after-care unit while they are on parole. In such multistage treatment programs, it is important to determine which stage in the treatment process has a greater effect on successful client outcomes. Teasing apart the components of treatment that work may also involve an effort to identify which therapeutic services contribute most to favorable client outcomes. Some programs can offer an array of services, including counseling, job training and referral, 12-step programs, and group therapy. If certain therapies consistently fail to change clients, that tendency points to a need to explore whether some types of clients might resist particular therapies. In such cases, an effort needs to be made to identify the reasons for client resistance and begin a search for appropriate therapies that might lead to better outcomes. In the next section, evaluations of in-prison drug treatment and community-based prison after-care programs are reviewed. An effort is made to determine if study designs employed in the evaluations of these programs make it possible to draw firm conclusions about their effectiveness in treating drug-using inmates and parolees. This is followed by a section on system-based treatment programs in the community. Since most drug users in system-based programs in the community are on probation, the section on drug treatment in the community begins with some background on how drug users are supervised on probation. Yet because probation supervision involves large caseloads, probation programs for drug users are often confined to monitoring and punishing drug-using probationers rather than treating them. Special offender management programs like TASC and drug courts often have to be set up to recruit proba-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us tioners and then link their monitoring and punishment to treatment. Hence, after some background about probation, the evaluation research on these programs is reviewed to determine if they are effective in helping their participants to achieve abstinence. TREATING DRUG USERS IN PRISON AND AFTER-CARE PROGRAMS In the past 20 years, prison populations have grown tremendously. The largest increase in the inmate population has occurred due to the rise in the number of persons incarcerated for drug possession and other nonviolent crimes related to drug use. For example, in 1980 there were 23,900 prisoners who had been incarcerated for drug use and drug sales. By 1998, that number had risen tenfold to 236,800 prisoners incarcerated for drug law violations (Blumstein and Beck, 1999; Beck, 2000). Presumably, many of these drug law violators could benefit from treatment while in prison. Prison-Based Programs A number of studies of prison-based programs seem to demonstrate positive postrelease outcomes when inmates who have gone through prison treatment programs are compared with those who have not (Wexler et al., 1992, 1996; Inciardi, 1996; Landry, 1997; Mullen, 1996; Wexler, 1996; Field, 1984). In particular, evaluations of one of the better-known prison therapeutic communities, called Stay’n Out, seem to indicate that participants in this prison treatment program experience a number of positive postrelease outcomes when they are compared with a control group that is not exposed to treatment (Wexler et al., 1992, 1996; Landry, 1997). In an evaluation of Stay’n Out, study subjects were drawn from a waiting list of inmates who had volunteered to participate in the prison therapeutic community. These volunteers were either randomly assigned to the treatment group (who actually enrolled in the therapeutic community) or to the control group who remained on the waiting list and never received treatment. The no-treatment control group included not only those randomly assigned to the waiting list, but also those who volunteered for treatment and were not admitted because they did not have enough time left to serve to complete the 12 months recommended for prison treatment. Because study subjects in both the treatment and no-treatment control groups volunteered for treatment, any findings from the study can be generalized only to inmates willing to volunteer for prison treatment pro-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us grams (Wexler et al., 1999). The subjects in this study cannot be said to represent those inmates who do not volunteer for in-prison programs. Both the treatment group and the no-treatment control group were followed after their release from prison. Outcomes were measured while they were on parole for a period of about 3 years after their release from prison. When comparisons were made between the male treatment participants and males in the no-treatment control group, subjects in the treatment group were significantly less likely to be rearrested while on parole than the no-treatment controls (Wexler et al., 1992, 1996). However, the findings were mixed as the subjects in the no-treatment control group actually delayed time until arrest longer than the treatment participants (15 months versus 13.1 months), although the differences were not significant. Moreover, the no-treatment control group was more likely to experience a positive parole discharge without technical violations, arrests, or revocation than the treatment group. Again, differences were not significant. The fact that the no-treatment control group fared as well as the treatment group on some measures of success indicates that this in-prison program did not change participants in ways so that they were any more likely to desist from criminal behavior and drug use upon release than a control group who had not received treatment. Additional problems with this study have to do with the outcome measures selected. Ideally, outcome measures should gauge the impact of in-prison drug treatment on reductions in drug use after release. After all, the effectiveness of in-prison therapeutic communities depends on their ability to change treatment clients in ways so that they will be less likely to use drugs after leaving prison. However, the outcome measures used in the evaluation of Stay’n Out are too global to gauge the impact of prison treatment on postrelease drug use as they include rearrests and parole violations for both drug crimes (drug use, drug sales, etc.) and nondrug crimes (robbery, assault, etc.). To measure the impact of prison drug treatment on postrelease rearrests and parole violations for drug crimes requires that drug crimes be singled out. Separating drug crimes from nondrug crimes also makes it possible to gauge how much harm paroled prisoners do upon their return to the community. If prisoners are reincarcerated for predatory nondrug crimes like robbery, then it suggests that they continue to pose a threat to the community. If they are rearrested or have their parole revoked for technical violations, like failing a urine test or refusing to attend a drug treatment program, then it is not clear that they necessarily endanger the community. Indeed some have raised questions about the fairness of reincarcerating drug users for such technical violations largely because

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us these violations do not indicate that such users pose a threat to the community (Petersilia and Turner, 1985; Clear and Terry, 2000). Also problematic from the standpoint of measurement is the use of rearrests and parole discharge as outcome indicators. Because so few episodes of drug use end in an arrest or parole revocation, it is doubtful that counts of study subjects rearrested or deemed parole violators accurately represent all incidents of relapse to drug use in the 3-year post-prison period. (The outcome measures and elements of the study design used in the Wexler et al., 1992 evaluation of Stay’n Out are summarized in Table E.1.) Apart from the problem with the use of questionable outcome measures, certain of these analyses raise questions about the oft-cited link between longer retention in treatment and more positive outcomes. Prison treatment staff recommend that participants in the prison therapeutic community remain in treatment for 9–12 months to complete each phase of therapy. And, as expected, those who stayed 9–12 months and com- TABLE E.1 Evaluations of Prison Treatment Programs   Random Assignment to Prison Treatment Random Assignment to Aftercare Outcome Measures Drug Outcome Measures Unsupervised Follow-Ups Stay’n Out Wexler et al., 1996 Yes Not apply —Rearrest —Months till rearrest —Positive parole discharge No No Key-Crest Inciardi, 1996 Martin et al., 1999 No No —Rearrests (excludes parole violations) —Self-reports and urine tests are voluntary No Amity Wexler et al., 1999 Yes No —Reincarceration —Days till incarceration No No Texas In-Prison TC Knight et al., 1999 No No —Reincarceration Urine test for parole supervision No

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us pleted treatment were more likely to experience positive outcomes upon release. In particular, they delayed the time until arrest longer than those who had stayed less than 9 months (Wexler et al., 1992). However, ever-longer stays in treatment did not always mean more positive outcomes. While those retained in the prison program for 9–12 months delayed rearrest for 18 months, those who stayed even longer—14 months—actually delayed arrest for only 12 months. Hence, those retained in treatment 9–11 months actually fared better than those retained longer at 14 months. Similarly, those who stayed in treatment 9–11.9 months fared better in terms of positive parole outcomes than those who stayed in treatment more than 12 months. Fully 77 percent of those retained for 9–11.9 months were positively discharged from parole, compared with only 57 percent of those who were retained for more than 12 months (Wexler et al., 1992). These findings raise questions regarding the time-tested link between retention and positive outcomes, as longer stays do not always translate into less posttreatment criminal behavior. In fact, these inconsistent findings are important enough that replication may be necessary to see if these surprising results show up in evaluations of other system-based treatment programs. Influence of Community-Based After Care The findings from the evaluation of Stay’n Out have enormous significance because they are based on comparisons between subjects randomly assigned to treatment or a no-treatment control group. The fact that the study shows that prison treatment has little to no impact on posttreatment outcomes raises doubts about the effectiveness of treatment in prison. However, some have argued that prison-based programs are more likely to bring about improvements if prison treatment participants continue to be involved in a therapeutic community after their release from prison (Inciardi, 1996; Martin et al., 1999; Wexler et al., 1999; Knight et al., 1999). Indeed, it is possible that after-care programs may have more influence on inmate improvements than prison treatment alone. If positive posttreatment outcomes are primarily due to treatment in the community-based after-care unit, it raises the possibility that the very expensive prison-based component is not really necessary. There may be some support for the notion that the community-based after-care unit is more important than the prison-based component of treatment. In a study of the Key-Crest program that combines a prison therapeutic community and a community-based therapeutic community for after care, Inciardi (1996) was able to determine the importance of prison treatment relative to the after-care program.

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us As might be expected, the data showed that clients who graduated from both the prison-based Key therapeutic community and the community-based Crest therapeutic community had the most positive outcomes in terms of drug-free and arrest-free status in a 6-month follow-up (Inciardi, 1996; Martin et al., 1999). The second most successful group included those with no prison treatment who underwent work release in the Crest therapeutic community after-care unit only. They were much more likely to be drug free and arrest free than those inmates who participated in the prison treatment program but underwent work release in the community in a unit without a therapeutic community. (The comparison group was the least likely to be arrest free and drug free of the four groups.) These rankings held in the preliminary 6 month follow-up. In a second follow-up after 18 months, the drug-free and arrest-free scores for all four groups were much lower; however, the rankings remained the same (Landry, 1997; Martin et al., 1999). The fact that those with community-based after care only outper-formed those with prison treatment only raises questions about how much influence prison-based therapeutic communities have on positive outcomes. On the basis of these findings, one could argue that the community-based after-care program was more instrumental in reducing relapse and recidivism than the prison-based program. Indeed, after examining the follow-up data, the Key-Crest researchers concluded that participation in a prison treatment program alone was not effective in bringing about drug-free or arrest-free status after release. In their view, successful outcomes depended on participation in the community-based after-care program (Martin et al., 1999). This finding that prison treatment alone was considerably less important than community-based after-care was borne out by research conducted on another prison treatment program called Amity (Wexler et al., 1999). Much like Key-Crest, the Amity program combined a prison-based therapeutic community with a community-based after-care program. Hence it was possible for Amity participants to begin their recovery in the prison-based therapeutic community and continue it in a community-based therapeutic community upon release. In the Amity program, volunteers for prison treatment were randomly assigned from a waiting list to either treatment or a no-treatment control group (Wexler et al., 1999). In this sense, the Amity program was different from the Key-Crest program as study subjects were not randomly assigned to prison treatment in the Key-Crest study (Wexler et al., 1999). Hence the Amity program controls for selection bias for those who participate in their prison program, whereas the Key-Crest program does not (see Table E.1 for study designs for both Amity and Key-Crest).

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us Finally, the fact that the TASC and non-TASC criminal justice system referrals had less severe drug problems and more use of alcohol and marijuana than clients who entered treatment without legal pressures raises questions about the way in which TASC and other criminal justice agencies screen drug clients for referral to treatment. A more recent study by Anglin et al. (1999) also examines the effectiveness of TASC programs, while avoiding many of the problems of the earlier research. Anglin et al. (1999) evaluated the effectiveness of TASC in five programs across the country that at least followed the TASC protocol. Of these five programs, three sites compared TASC clients with a comparison group that had not been randomly assigned. Evaluations in these three sites are difficult to interpret due to the potential for self-selection bias. However, the other two sites in Canton and Portland did use an experimental design. At the Canton and Portland sites, study subjects were randomly assigned either to treatment programs that used the TASC offender management model or to a treatment program that did not use the TASC model. (The alternative program may not have monitored users in treatment as effectively as those in TASC-monitored programs.) Hence Anglin et al. (1999) were comparing clients in two different types of treatment rather than examining TASC clients side by side with a no-treatment control group (see Table E.2). At one of the two sites located in Portland, TASC clients did no better than those in the non-TASC alternative treatment group. However, TASC clients at the second site in Canton fared better than the clients in the non-TASC treatment alternative on one measure of drug use. TASC clients who reported heavy drug use in the six months prior to intake reduced their drug use much more between intake and follow-up than heavy users in the non-TASC alternative treatment group. On the basis of this finding, Anglin et al. (1999) concluded that TASC could bring about significant reductions in drug use. However, it is important to remember that TASC clients were being compared with clients in the non-TASC alternative treatment group. The TASC clients were not compared with a no-treatment control group, so this study says little about whether TASC is more effective than no treatment at all. These findings are difficult to interpret for another reason. Measures of drug use for both the intake and follow-up interviews are based on self-reported levels of drug use. This makes it difficult to figure out which group was actually more successful. It is conceivable that the TASC clients actually reduced their drug use more between intake and follow-up than the non-TASC alternative treatment group, as the authors concluded. It is also possible that the TASC clients were simply more likely to report large reductions in drug use than those in the non-TASC alternative group. Certainly the TASC clients would have been well aware of the

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us high risk of being punished for repeated drug relapses, in light of their ongoing involvement in the TASC program. This could have easily made them more reluctant to report. In other words, when respondents are asked to report on their drug use in a setting in which they are being heavily monitored and reports of drug use can lead to punishment, the potential for underreporting is quite substantial (Harrison, 1997). This makes it difficult to know what to make of the significant declines in drug use reported by the TASC subjects. Despite the questionable nature of these two studies on TASC, this research did demonstrate that the program could induce drug users to stay in treatment longer than voluntary clients. This led to renewed interest in the use of punishment or threats of punishment to induce drug users to remain in treatment. With recent increases in the number of drug users brought before the courts, this notion that client recovery is more likely to occur when punishment is linked to treatment is once again a matter of some importance. DRUG COURTS Linking treatment to punishment is an issue that is once again garnering some attention as there has been a near tripling of drug arrests in the last 20 years (Flanagan and McLeod, 1983; Bureau of Justice Statistics, 1999). Nearly 80 percent of drug arrests are for possession, and half of current possession arrests involve those caught with small amounts of marijuana. By the late 1980s and early 1990s, the courts became overwhelmed by this huge influx of new drug cases, and some judges began to look for a solution in the form of drug courts. The first drug court was established in Florida in 1989 and, since that time, there has been a rapid expansion in the number of jurisdictions with these courts (U.S. General Accounting Office, 1997; Belenko, 1998). Like TASC, drug courts aim to combine treatment and punishment in an effort to speed client recovery. Judges were motivated to urge the development of drug courts since they were seeing the same people over and over as they were returned to court for their repeated relapses for drug use or for their rearrests for recurring criminal acts potentially caused by drug use. It was also clear that punishment alone had failed to stop these drug relapses or criminal recidivism, and so there was a renewed emphasis on linking the courts to treatment (Belenko, 1998). The hope was that if the courts required drug offenders to enter and remain in treatment, many would be rehabilitated. If their drug use and their drug-related criminal behavior could be stopped or reduced, they would cease to be a burden on the courts. Moreover, if drug courts could mandate treatment that brought about such positive outcomes, then they could also reduce jail and prison overcrowd-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us ing. To address these problems, drug courts were set up as designated courtrooms that were specifically geared toward linking drug users to treatment and monitoring their therapeutic progress (Belenko, 1998). Much like TASC, drug courts identified the drug users in the criminal justice system and referred them to community-based treatment programs. They also monitored participants’ progress in treatment and had the option of returning them to court for further sanctions if they failed in treatment. And like TASC participants, drug court participants could see their cases dropped if they completed treatment. While there are a number of similarities between drug courts and TASC, drug courts are more judge-centered. Drug court participants are regularly required to appear before a judge in a status hearing, in which judges and other court personnel try to help participants address problems with drugs, work, and family life. Drug courts also determine if participants are regularly attending treatment and take reports from treatment providers regarding client progress. Drug court participants are also regularly required to submit urine tests so the courts can determine if they are remaining drug free. If drug court participants miss court hearings, fail to go to treatment sessions regularly, have an excessive number of positive urine tests, or get rearrested while in the drug court program, a number of sanctions are at the judge’s disposal (U.S. General Accounting Office, 1997; Belenko, 1998). Judges can make use of “motivational jail time,” in which a participant serves a short stint in jail as punishment for these infractions. The judge may also terminate an errant client from the program and send them back to court. Termination from treatment can have serious implications for the relapsing drug user, as it can mean reinstatement of the original criminal charges. For some users, this could lead to an extended period of incarceration in jail or prison. Although there have been approximately 20 evaluations of drug court programs (U.S. General Accounting Office, 1997; Belenko, 1998), the programs vary so much in terms of their eligibility requirements, the specified program length, the types of treatment offered, and the degree of coercion they apply, that it is almost impossible to generalize about whether they are effective or to estimate an effect size. Because the data needed to evaluate these programs are often sketchy and incomplete, it is perhaps best to settle on identifying issues that might be addressed in future evaluations rather than attempting to draw any conclusions about their effectiveness based on the data that are currently available: • Measuring Drug Court Effectiveness. Very few studies look at post-program effects. Moreover, many studies simply compare drug court par-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us ticipants who graduate from the program with drug court participants who drop out. Comparisons between drug court graduates and drug court dropouts introduce self-selection bias, as graduates may fare better than dropouts because of their own commitment to abstaining from drugs rather than program effects. The more appropriate way to measure effectiveness is to compare all drug court participants—graduates and dropouts—to a control group that did not participate in a drug court program (Belenko, 1998; U.S. General Accounting Office, 1997). Even in the handful of studies that make appropriate comparisons between all drug court participants (dropouts and graduates) and a control group, no mention is typically made of what percentage of those eligible for these programs were willing to participate. Yet if very few persons brought before the courts are willing to volunteer to participate in these programs, they will ultimately do little to relieve overburdened courts. Furthermore, since the willingness to volunteer for a drug court program may vary from court to court, depending on what other options are available with standard adjudication, it may be difficult to generalize any findings on the willingness to volunteer from one court to another. In addition, very few studies make use of experimental designs in which drug court participants are compared with a no-treatment control group. However, in one study of the Maricopa County drug court, study subjects were randomly assigned to either a drug court or traditional probation and followed over a 3-year period (Turner et al. 1999). In the 3-year follow-up, drug court participants were less likely to be rearrested than those on traditional probation. Indeed, the Maricopa County study compared drug court participants with those on traditional probation in terms of a number of outcome measures, including rearrests for drug crimes and non-drug crimes as well as for convictions or reincarceration in jail or prison during the 3-year follow-up. As noted previously, it is doubtful that outcome measures such as rearrests, convictions and reincarcerations can provide accurate counts of drug use levels or criminal behavior in a follow-up period. After all, many of the subjects in this study could have easily managed some episodes of drug use or criminal behavior in the follow-up period without being rearrested or reincarcerated. Hence it is difficult to know what to make of the drug court participants’ lower overall rearrest rates for all crimes. Not only did the Maricopa County study rely on some of the same questionable outcome measures used in other evaluation studies, but it likewise confined its follow-up period to the 3 years that the subjects were subjected to criminal justice supervision (Turner et al., 1999). Yet follow-ups that occur after criminal justice supervision is over are important because they make it possible to determine if drug court participants are

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us more likely to stay off drugs than those who underwent traditional probation, even when they are not being monitored or subject to the threat of punishment. Finally, while it is understandable why study subjects in Maricopa were randomly assigned to either a drug court or traditional probation, it should be noted that traditional probation does not qualify as a no-intervention control group. After all, the study subjects on traditional probation were being monitored and punished for any infractions. Hence, this study compares drug court participants, who receive treatment, monitoring, and sanctions, with a traditional probation group that receives the monitoring and sanctions associated with probation. The study does not include a no-treatment/no-supervision control group who experience no criminal justice interventions. This is unfortunate given the fact that the criminal justice net has been widened in recent years to include many minor drug users who look little different from their age-mates who manage to mature out of drugs without treatment or supervision. This study can cast little light on whether any reductions in drug use made by either drug court study subjects or study subjects on traditional probation are due to punishment or treatment or both, or simply the process of maturing out of drug use that occurs at that age. • Cost Savings. It is likely that future evaluations will make an effort to determine if drug courts can achieve cost savings. To achieve cost savings, these programs must significantly reduce the drug use and criminal behavior of program participants. If they succeed, drug court program graduates will be less likely to be sent to jail for extended periods of incarceration, and they will be less likely to be sent to more expensive prisons for longer sentences (Inciardi et al., 1996). To date, no systematic analysis exists to determine whether drug courts generate cost savings (U.S. General Accounting Office, 1997; Belenko, 1998). However, any attempt to assess cost savings will require some understanding of what types of people end up in drug courts. If drug courts mainly draw people who would otherwise go to prison or jail for extended periods, and if they succeed in reducing their criminal behavior and drug use, then they are likely to generate very impressive cost savings. If they mainly draw people who might otherwise undergo supervision with traditional probation, then they will have to be very successful in reducing post-program drug relapses and criminal recidivism to justify higher costs than those associated with traditional probation. Given the preliminary nature of much of the drug court data, it is difficult to determine if alternative court dispositions for drug court participants would be more or less expensive.

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us • Treatment Effectiveness. Because all drug courts refer clients to treatment and monitor their progress, they do a better job of linking the criminal justice and drug treatment systems than older forms of community supervision, such as traditional probation or intensive probation supervision programs. However, this can be considered a desirable feature only if they link them to effective forms of treatment. Many drug courts refer clients to self-help programs like Alcoholics Anonymous, Cocaine Anonymous, and Narcotics Anonymous (U.S. General Accounting Office, 1997). Of these three 12-step programs, only Alcoholics Anonymous (AA) has been subjected to a fair amount of evaluation (Landry, 1997). The research on AA suggests that it could be effective; however, efforts to evaluate it are typically stymied by self-selection biases. In short, it is simply not clear whether those involved in A A improve because of their participation in the program or whether they participate in A A because they are already committed to making improvements. The same potential for self-selection bias also limits the capacity to determine the effectiveness of the less-evaluated 12-step programs like Narcotics Anonymous and Cocaine Anonymous. Drug courts also refer a large number of clients to outpatient drug-free programs (Belenko, 1998). However, the term “outpatient drug-free” refers to a miscellany of programs that vary in terms of the services they offer and may include individual or group counseling, addiction or AIDS education, acupuncture, and/or training in social skills (U.S. General Accounting Office, 1997; Belenko, 1998). This makes it very difficult to determine if the treatment component of drug courts has any lasting and positive effect on outcomes, since it is often unclear which services are offered by different outpatient drug-free programs. Not only is it unclear which services ensure positive post-program outcomes, but it is also unclear whether retention in drug courts is a predictor of post-program successes. In part, this is because it has been difficult to define retention rates in drug courts (U.S. General Accounting Office, 1997; Belenko, 1998). Estimates suggest that, on average, 43 percent of drug court participants are retained in treatment (U.S. General Accounting Office, 1997). This figure is quite high for treatment programs—especially outpatient drug-free programs, which generally have high dropout rates (see Belenko, 1998). Yet it is not entirely clear whether longer retention translates into more positive outcomes. Retention certainly has had a close association with positive posttreatment outcomes in earlier literature on voluntary treatment programs that are disengaged from the criminal justice system. But with system-based programs that link treatment and punishment, the meaning of retention may change. It is simply not known whether legal sanctions ad-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us ministered by the courts will have the effect of “manufacturing” commitment in people who were not previously committed. Moreover, there is a possibility that some of the therapeutic services offered by drug courts may actually generate client resistance to treatment. In particular, the individual and group counseling offered by a number of outpatient drug-free programs and therapeutic communities may be inappropriate for some clients. Working-class and low-income clients, in particular, have been known to resist this type of therapy because they find it difficult to confide personal matters to a stranger or a group of strangers in counseling sessions (Currie, 1993; Covington, 1997). For these clients, treatment may be wholly ineffective and yet, if they fail to attend sessions, they may be punished with “motivational” jail time or be returned to court to be prosecuted for their original crime. In such cases, requiring clients to participate in these potentially alienating therapies may set some up to fail in treatment and be subjected to further sanctions. Finally, preliminary research suggests that drug courts may do well with those who already have a stake in conformity. It also suggests that they are not very effective with those who lack such a stake. In other words, they fail with the clients who are most likely to fail in other types of treatment, including the unemployed, the less educated, and those using hard drugs like cocaine (Peters et al., 1999). If this is borne out in future research, it means that drug courts may ultimately be incapable of changing those who are most likely to burden the courts. CONCLUSION Clear-cut answers to questions as to whether programs that link treatment to punishment can effect long-term changes in client drug-using and criminal behavior are difficult to come by. Evaluations of these programs have not been very revealing because many of these studies have been hobbled by poor study designs. For one thing, study subjects are not always randomly assigned to treatment or no-treatment control groups, making it difficult to know whether client successes are due to program effects or to a client’s commitment to abstain from drug use. Equally worrisome is the problem of identifying valid outcome measures of drug use and criminal behavior in the follow-up period. While client self-reports of drug use and crime have been used to measure outcomes in the follow-up, using self-reports with respondents who have recently been punished for their drug use may result in severe problems with client underreporting. Rearrests, convictions, or reincarcerations are also questionable measures, because so few episodes of drug use or criminal behavior come to the attention of the criminal justice system and get re-

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Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us corded in these official statistics. Furthermore, much of the evaluation research on criminal justice programs makes use of inappropriate follow-up periods while clients are still on probation or parole. It is important that clients in system-based programs be followed after criminal justice supervision has ended because such post-supervision follow-ups make it possible to determine if these programs actually induce users to abstain when they are not being monitored. Design flaws in much of this research preclude any definitive answers regarding program effectiveness. ACKNOWLEDGMENT The author wishes to thank Richard Bonnie, Robert MacCoun, and two anonymous reviewers for their comments on earlier drafts of this paper. She is especially grateful to Faith Mitchell at the National Research Council for her participation in this project. REFERENCES Anglin, M.D., D.Longshore, and S.Turner 1999 Treatment alternatives to street crime. Criminal Justice and Behavior 26(2):68–195. Bachman, J., K.Wadsworth, P.O’Malley, L.Johnston, and J.Schulenberg 1997 Smoking, Drinking, and Drug Use in Young Adulthood: The Impacts of New Freedoms and Responsibilities. Mahwah, MJ: Lawrence Erlbaum Associates Beck, A. 2000 Prisoners in 1999. Bureau of Justice Statistics Bulletin. Belenko, S. 1998 Research on drug courts: A critical review. National Drug Court Institute Review Biernacki, P. 1986 Pathways from Heroin Addiction: Recovery Without Treatment. Philadelphia: Temple University Press. Blumstein, A., and A.Beck 1999 Population growth in U.S. prisons, 1980–1996. Pp. 17–61 in M.Tonry and J. Petersilia, eds., Crime and Justice, Vol. 26, Prisons. Bureau of Justice Statistics 1999 Drug and Crime Facts—Drug Law Violations. Available online at http://www.ojp.usdoj.gov/bjs/dcf/enforce.htm 2000 U.S. Correctional Population Reaches 6.3 Million Men and Women, Represents 3.1 Percent of the Adults U.S. Population. Press Release. Available on-line at http://www.ojp.usdoj.gov/bjs Camp, G.M., and C.G.Camp 1999 The Corrections Yearbook, 1998. Middletown, CT: Criminal Justice Institute. Clear, T.R. 1999 Leading from and leading toward. Corrections Management Quarterly 3(1):14–18.

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