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4 Defining the Goals of Treatment A wide range of hopes have been fastened on drug treatment, in keep- ing with the diversity among those who take a strong interest in treatment programs: clients, their families, clinicians, outside payers, employers, and public agencies. How these different expectations can be reconciled and prioritized is a fundamental question--- particularly for the development of measures to assess treatment outcome. Such assessments are in turn cru- cial at a time when competition for budgetary dollars is intense and health cost control measures are targeting substance abuse benefits for differential reductions even though the public and the President rank the drug prob- lem above national security and economic concerns as the country's most serious current issue (Gallup, 1989; Bush, 1990~. Every treatment program needs to have operational goals, which should be clearly understood and viewed as legitimate by all interested parties. These goals imply how program success is to be measured. Changes in the frequency of program clients' cocaine or heroin consumption and in their commission of (and subsequent apprehension for) violent crimes are typically the dominant themes of treatment outcome studies. With limited exceptions, changes in physical and psychological well-being, marijuana and alcohol consumption, general employment status, and the size of local drug markets are subsidiary issues. AIDS risk reduction as a measure of treatment outcome is only beginning to assume importance. This chapter first reviews the diverse interests that have shaped treat- ment, the interplay between these interests, and their implications for setting realistic treatment goals. The committee focuses especially on client 105

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106 TREATING DRUG PROBLEMS motives for entering treatment. What finally spurs most clients into treat- ment is the desire to relieve some kind of immediate drug-related pressure or to avoid an unpleasant drug-related consequence. Concerns about legal jeopardy loom large among these motives and have been analyzed more extensively than all other factors combined. In this chapter, therefore, the committee carefully examines how the criminal justice system affects the drug treatment system and particularly considers the implications for treatment of the large and growing pool of drug-involved individuals over whom the justice system exerts (or tries to exert) various kinds of authority. Besides the criminal justice system, the workplace is the most significant formal institution potentially affecting referral to treatment, particularly through employee assistance and drug screening programs. Estimated productivity losses owing to drug problems add up to an impressive figure. There is limited evidence, however, about the connection between employee assistance or drug screening programs and drug treatment, and the data suggest that employer linkages are not a big part of the total treatment picture. The various and complex motives displayed by clients in treatment, the differing severities and depths of their problems, and the differential involvement of the criminal justice system or employers yield a spectrum of potential with respect to recovery from drug problems. Programs in turn have developed strategies for selecting or recruiting across that spectrum, within the limits of their clinical resources, organizational commitments, and institutional environments. Partial recovery, particularly in terms of reduced drug consumption and other criminal activity, is a realistic expectation for most clients in treatment at any one time. Full recovery is an achievable goal only for a fractional group, whereas no recovery can be expected for another fraction. In light of these observations, the most general conclusion of this chapter is that in setting and evaluating treatment goals, what comes out must be judged relative to what went in and as a matter of more or less rather than all or none. DIVlERSE INTERESTS The notion of successful drug treatment has many possible shad- ings. A number of drug treatment goals have been overtly or implicitly advanced in authoritative statements over the years (American Bar Asso- ciationJAmerican Medical Association, 1961; Office of Drug Abuse Pol- icy, 1978; Office of National Drug Control Policy, 1989; Besteman, 1990; Courtwright, 1990~. These goals are diverse enough that success in reaching

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DEFINING THE GOALS OF TREATMENT 107 one of them (although it may be related to other goals) is not necessarily a requirement for success in reaching the others. The following is a compendium of many of these treatment goals: substantially reduce the treated individual's use of illicit drugsor, more stringently, end it altogether; substantially reduceor end altogether violent and acquisitive crimes by the treated individual against others; substantially reduceor end altogether the treated individual's consumption of legal psychoactive drugs, including alcohol and medical prescriptions such as methadone; reduce the treated individual's specific educational or vocational deficits; restore or initiate legitimate employment of the treated individual; change the treated individual's personal values to approximate more closely mainstream commitments regarding work, family, and the law; normalize or improve the treated individual's overall health, longev- ity, and psychological well-being; reduce specific drug injection practices and hazardous sexual behav- iors, such as multiple unprotected sexual encounters, that readily transmit the AIDS virus between the treated individual and others; reduce the overall size, violence, seductiveness, and profitability of the market for illicit drugs; and reduce the number of infants born with drug dependence symptoms or other immediate or longer term impairments owing to intrauterine exposure to illicit drugs. The length of this list of goals and the specific variations within it (reducing versus ending a certain behavior, individual versus more broadly sociological effects) have two distinct although related origins. First, dif- ferent governing ideas about drugs have instilled different aspirations, the- ories, and philosophies into the treatment system. Second, drug treatment episodes involve multiple parties, and the ultimate results of any treatment episode are shaped by the differing objectives and behavior of those parties. Analytically, the parties involved in drug treatment are individual clients entering treatment; clinical programs themselves, which offer different types of services; third-party reimbursers or payers of clinical expenses (e.g., in- surers or public health bureaus); regulatory agencies or other monitors such as accreditors or utilization managers, who enforce or evaluate program compliance with specific legal or clinical standards; family members or others who are personally involved with individuals entering treatment; agencies that have legal or client relationships with these individuals, such

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108 TREATING DRUG PROBLEMS as cnminal~ustice agencies or employers; and the public through its appointed and elected representatives.] The goals of clients, clinicians, program managers, payers, regulators, politicians, and other interested parties are often imperfectly matched. Con- flicts and competition for control of clinical decision making are common. This pattern is visible not only in particular cases but also more broadly, as drug treatment policies, practices, and capabilities evolve with accumulating experience and vary with the changing balances between governing ideas. For example, the moral censure of drugs and the desire to reduce the prevalence of drug-related crime were early and clear influences on the development of publicly supported treatment programs. It is impossible to understand the growth of the national treatment system apart from the national policy focus on cutting down street crime. But compassion for the suffering of the addict has also been a factor, together with a strong current of concern, especially in the 1960s, about improving economic opportunities in urban neighborhoods badly troubled by poverty, drugs, racial discrimina- tion, and other problems. Concern has centered as well on protecting the civil rights and restoring the human dignity of drug-dependent individuals. In this context, community programs were viewed as a source not only of therapy for the treated individual and crime control for all of his or her neighbors but also of jobs, identity, community empowerment, and political achievements (Vocational Rehabilitation Administration, 1966; Brotman and Freedman, 1968; Martin and Isbell, 1978; Attewell and Gerstein, 1979; Besteman, l990r, Courtwright, 1990~. In contrast, most privately reimbursed drug treatment programs began with a much firmer adherence to the medical perspective associated with treating dependence on alcohol as a disease, a perspective with very dif- ferent legal ramifications and in particular an orientation toward restoring employees to satisfactory job performance. Private treatment programs have also placed great emphasis on the dignityor destigmatization of the afflicted individual (Wiener, 1981; Institute of Medicine, 1990; Ro- man and Blum, 1990~. More recently, the fear of harmful or criminal behaviorincluding drug transactions at the work site and negligence in job performance that might lead to injury or loss of life has become a 11hese categories of interest in treatment are not necessarily separate in practice. Family mem- bers may have legal relations with the individuals in treatment in the form of marital and parental responsibilities; the family or the individual may take full or partial financial responsibility for treatment charges; employers and criminal justice agencies are not only bound to some individ- uals in treatment by formal contracts or writs but may also be paying for the treatment; payem such as state agencies often double as program regulatom; employers, agents of justice, and, of course, clinicians often develop strong personal concern for their clients within the professional framework of service or supervision. Furthermore, although some parties to treatment deal with each other only in a single episode, others do so across many episodes.

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DEFINING THE GOALS OF TREATMENT 109 significant factor as well (Gust and Walsh, 1989~. Most recently, high levels of concern about increasing expenditures on private treatment for drugs, alcohol, and mental illness (and every other health cost) are affecting the private treatment sector. Plurality of interests is not a phenomenon unique to drug treatment, and it is not an insuperable obstacle to setting achievable goals. Even with clearly divergent intentions, different parties may be able to strike a bargain that is, agree on a "social contract" for treatment that everyone involved considers favorable, even though each party may get something lessor more- than it originally bargained for. The major result of com- plenty for present purposes is that it makes treatment processes highly contingent. If participants have differing goals, treatment processes are more susceptible to breakdown through client attrition or discharge, staff demoralization or mismanagement, program closing, or withdrawal of par- ticipation by a payer or other external agent. In light of the diversity of treatment goals and the differing motives that underlie them, it is important to develop realistic expectations about what treatment can usefully accomplish. The principal issues reduce to a few central and relatively enduring questions: Why do individuals enter drug treatment? What are the implications of entry motivations for setting clinical goals? What are the actual and the optimal goals of drug treatment and the criminal justice system? What are the supporting relationships between them? Between drug treatment and employers? What should be the minimum acceptable results of treatment partial or only full recovery? REASONS FOR SEEKING TREATMENT Individuals who seek admission to drug treatment offer a variety of rea- sons for doing so (Anglin et al., 1989b; Hubbard et al., 1989~. The reasons they give are illuminating, although their logic proves to be unintelligible in some cases, and they may be evasive or deceptive in others. Three fun- damentals are present in virtually every such instance. First, the applicant for admission to drug treatment has one or more uncomfortable and fairly urgent problems to resolve. Typically, the problems entail noxious physical or psychological stimuli (a serious infection, chronic depression), sharp social pressure (a felony case, an angry spouse), or the imminent threat of something quite unwelcome (e.g., imprisonment or assault). Second, the problems are related to drug use, although the client may or may not view them as issues separate from drug consumption. In fact, the relative severity of drug abuse or dependence may be only loosely coupled with the severity of the presenting problem. Third, the individual is ambivalent about seeking treatment.

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110 TREATING DRUG PROBLEMS Motives do not necessarily translate directly into outcomes. Reconfig- uring client motivation is a fundamental clinical objective of many if not all good treatment programs. Moreover, there is reason to think that treat- ment processes affect individuals to some degree regardless of their initial motives. Nevertheless, the cardinal importance of the initial motivation to seek treatment is that these motives are likely to influence the probability that the client will stay in treatment long enough for the therapeutic pro- cess to take effect. For this reason, it is worthwhile to delineate treatment motivations in some detail. The kinds of problems that lead applicants to seek treatment are well summarized in the scales of the Addiction Severity Index, a diagnostic screening interview and rating method designed to yield "a subjective estimate of the client's level of discomfort in seven problem areas commonly found in alcohol and drug dependent individuals" (McLellan et al., 1985:iii). The following categories are rated for severity: medical status (lifetime hospitalizations [excluding drug detoxifica- tion or treatment], chronic medical conditions, disabilities, severe symptoms in past 30 days [excluding drug withdrawal, intoxication, or overdose ef- fects]~; employment/support (level of formal education and training, occu- pational type? usual employment pattern, past 30 days' employment, income level and sources, dependents, recent job-finding efforts [if applicable]~; drug use (use during past 30 days, recent dependence/abuse symp- toms, lifetime use, length and date of last abstinence, lifetime overdoses and detoxifications, previous treatment episodes, recent daily cost of drugs); alcohol use (use during past 30 days, recent dependence/abuse symptoms, lifetime use, length and date of last abstinence, lifetime over- doses and detoxifications, previous treatment episodes, recent daily cost of alcohol); legal status (whether legal jeopardy prompted application, whether client has an active case pending or is on probation or parole, lifetime arrests by type, number of convictions and incarcerations, recent crimes committed); family/social relationships (marital status and satisfaction, living ar- rangements and satisfaction, relations with friends, recent and past conflicts with family or friends); and psychiatric status (treatment episodes, symptoms of depression, anxiety, confusion, or aggression during lifetime and in past 30 days, suicide attempts). The literature on admission to treatment, much of which reports on the use of the Addiction Severity Index or similar instruments and reflects an abundance of clinical experience, indicates that treatment is sought

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DEFINING THE GOALS OF TREATMENT 111 primarily when there is a negative or threatening situation to be alleviated in any oneor moreof these areas thrown et al., 1971; Ball et al., 1974; Gerstein et al., 1979; Hubbard et al., 1989~.2 Moreover, studies show that applicants often report either an unsuccessful attempt to deal with the admitting complaint without seeking treatment or an earlier successful resolution of this or a similar problem (at least temporarily) with the aid of treatment. Because some problems can be intermittent, yielding to quick solutions but returning again and again to trouble and frustrate the individual, initial brief flirtations with treatment are often followed by later, more extended episodes. In fact, half or more of a mature program's admissions can be expected to be repeat admissions to that program without counting time spent in other programs. The prevalence of repeat admissions is generally highest in methadone programs, which require documentation of previous relapses and have the oldest clientele. In a typical long-standing methadone program, two-thirds of the clients are second or later admissions (Allison et al., 1985; Hubbard et al., 1989~. Controlling drug use is virtually always a part of treatment motivation, but the extent or proportion of that part varies. It may be the sole objective of treatment entry, or it may be no more than a base from which superordinate objectives are to be achieved. These objectives can be very specific: for example, to withdraw completely from a local drug market to avoid violent recriminations for a dishonest transaction (stealing someone's drugs, acting as a police informant, etc.~; to influence a prosecutor or judge to reduce a heavy criminal charge or sentence, thus yielding probation rather than jail or a shorter rather than longer term of incarceration; to complete probation or parole successfully; to save a job threatened by drug-related absenteeism, ill temper, or errors; or to stave off a family rupture, such as expulsion from a conjugal or parental home or the loss of custody of a child. 2Because a large proportion of the available research literature on patterns of drug treatment motivation is drawn from studies of heroin addicts entering methadone and residential treatment in the 1970s, caution should be used in generalizing those findings to drug usem of today. On the other hand, the street heroin addict of the 1970s was usually an experienced polydrug user, familiar with all manner of opiates (codeine, morphine, propoxyphene, dihydromorphinone), cocaine (always popular for intravenous or other use but not as widely accessible or as cheap as it is today), amphetamines, alcohol, marijuana, barbiturates, and other drugs. The heroin addict was distinguished largely by a strong preference for that drug, assuming its availability. Patients entering residential and methadone programs today are similar to those of earlier years but gen- erally have higher levels of nonopiate use, especially cocaine. The durability over the years of drug experience patterns and other characteristics may also be true of outpatient counseling pro- grams, whose clients have tended on the whole to be younger, less desperate economically, and more often oriented toward psychological interpretations of their problems (Sells et al., 1976; Hubbard et al., 1989~. Seldom opiate users, these clients were and are heavy users of marijuana, alcohol, and now cocaine.

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112 TREATING DRUG PROBLEMS The motives can also be quite general: to restore generally run-down physical health; to put one's life back together; or to find or regain a sense of self-respect. Perhaps the most general of reported motives is a pervasive sense of weariness or melancholy, a cumulative and demoralizing realization that the increasing trouble that comes with sustained abuse and dependence is leading to a dead end. Depending on the modality, one- quarter to one-half of a national sample of treatment admissions reported depressive and suicidal thinking (Hubbard et al., 1989~. Recently (Kosten et al., 1988), as well as in previous years (Allison et al., 1985), health crises, problems involving serious jeopardy from the criminal justice system, and psychiatric/psychological problems are the most prominent motivations among those seeking relief from cocaine and opiate use in public programs.3 In the case of women or married men, pressure precipitating admission to treatment often comes from family members; however, in general, these demographic types are a minority of those entering public programs. Pressure from the criminal justice system is the strongest motivation reported for seeking public treatment. Those who entered outpatient and residential programs in a 1979-1981 national sample of public program admissions were directly referred by the criminal justice system about 40 percent of the time. Direct referral, however, is clearly a conservative measure of the broader influence of criminal justice pressure (Anglin et al., 1989b). Between one-half and two-thirds of admissions to these modalities had some form of legal supervision such as parole or probation. Very few methadone clients less than 3 percent were directly referred by justice agencies in the 1979-1981 sample (Allison et al., 1985; Hubbard et al., 1989), but probation or parole status was quite common. In other studies, large proportions of methadone clients have indicated subjectively perceived pressure involving their legal status (Anglin et al., 1989b). Court orders or other criminal justice system referrals to treatment are not unknown in private programs, particularly in outpatient modali- ties (Harrison and Hoffmann, 1988; Hoffmann and Harrison, 1988~. But it seems likely that these referrals are mostly drinking/driving rather than drug cases (the published statistics on private programs are dominated by alco- hol admissions and do not differentiate motivations by primary substance problem). Threats from employers or family members as well as psycho- logical anguish and personal health problems are prominent motivators in private-tier programs. The implications of criminal justice involvement in an admission to drug treatment are important. Clinicians recognize that an applicant who 3 Chapter 6 more thoroughly delineates how the public tier of programs differs from the private tier.

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DEFINING THE GOALS OF TREATMENT 113 is on parole or probation or who has a case currently in court automatically brings a second (and perhaps a third or fourth) "client" along that is, the parole officer, defense attorney, prosecutor, judge, and so forth. Sorting out the effects of program activities on the clinical client versus their effects on the criminal justice client is no easy matter. Is an individual to be counted a treatment success or a treatment failure if he or she complied perfectly with treatment rules but dropped out of treatment early when convicted and imprisoned on a preexisting felony charge and is still in prison at the 12-month follow-up? Is a client a treatment success or a treatment failure if he or she is on probation, refrains from drug-seeking behavior, but continues to live by larcenous activities avoiding rearrest during the 12- month follow-up period? Should the client whose parole officer insists on almost daily contact be equated analytically with the client whose probation officer wants no more than a quarterly postcard? The client's progress during or after treatment may depend heavily on the detailed conditions of criminal justice supervision that applied when the client entered treatment. 1b understand this connection requires a closer look at the relationship between the criminal justice and treatment systems. CRIMINAL JUSTICE AGENCIES AND TREATMENT According to the estimates presented in Chapter 3, more than a million individuals now in custody or under criminal justice supervision in the community need drug treatment. Approximately 1 in 10 of these individuals is estimated to be currently in treatment; probably a similar number have had previous exposure to treatment. These figures indicate the significance of the criminal justice system as an environment for drug treatment an important environment now as it has been in the past (see Besteman, 1990; Courtwright, 1990; Phillips, 1990~. In the eyes of the public, criminal offenders constitute the most worrisome component of the drug problem and bulk large in estimates of the costs to society of drug use. It is difficult to envision any expansion of drug treatment without an expansion in its overlap with the criminal justice system (sharing of clients/supervisees/inmates). Linkages between the justice and treatment systems occur at numerous points. Drug-involved offenders are sometimes sent to treatment rather than adjudication, a process known as pretrial diversion. Many courts and correctional systems use commitment or referral to community-based treatment programs as an adjunct to probation or conditional release (parole) from prison. There is also treatment within correctional facilities and correctionally operated or funded halfway houses. Although the number of individuals in the criminal justice system as a result of drug-induced offenses has always been appreciable, it is

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114 TREATING DRUG PROBLEMS much greater now than in the past even as recently as 5 years ago. This increase is due to the 15-year trend of massive growth in the criminal justice system itself and in particular to the growth in volume of its correctional services that is, time behind bars. Between 1973 and 1988, the number of arrests made annually by police increased an estimated 50 percent, from 8 million to nearly 13 million much faster than the increase in the U.S. population. Overall, the police concentrated nearly all of this increased attention on adults: for example, from 1978 to 1987, the number of juvenile arrests declined by 13 percent whereas the number of adult arrests increased by 37 percent. (These shifts greatly exceeded changes in the age distribution of the population.) Adult arrests for drug crimes have increased disproportionately: an estimated 848,000 out of 937,000 total drug arrests in 1987 were adult offenders (Jamieson and Flanagan, 1989~. The consequences of arrest have also changed, and there is now a much greater likelihood than in the past that an individual convicted of a crime will spend time in custody and under subsequent community supervision. In 10 years, from 1978 to 1987, the average daily jail census nearly doubled, from 156,000 to 290,000; in 15 years, the prison census more than tripled, from 204,000 in 1973 to 625,000 in 1988 (Figures 4-la and 4-lb). Periods of imprisonment for felons sentenced to state prisons now average 2 to 3 years; the average imprisonment is somewhat less for drug offenses and somewhat more for violent offenses (e.g., 3 to 5 years for robbery, 7 years for homicide). Total sentences extend much longer than the time served in prison. Under widespread mandatory release rules, about 45 percent of the sentence is usually spent in prison initially, with the remainder on parole, not counting reincarceration time as a result of parole violation. Altogether, about 3.3 million individuals were under criminal justice supervision of one sort or another on the designated census days in 1987 compared with 1.3 million in 1976. Three out of four of these individuals were in the community rather than behind bars. Court Referral to Treatment The largest effort to bring adjudicated populations into contact with treatment is court-ordered screening to assess suitability for placement in community-based treatment programs under pretrial or posttrial probation. A series of these types of court-related programs were organized beginning in 1972 under the Treatment Alternatives to Street Crime (TASC) program (Cook et al., 1988~. Originally created mainly to serge opiate addicts, the program soon became a common mechanism for diverting lesser drug cases, such as marijuana possession in small amounts, to avoid "clogging the justice system" with offenders who were nonviolent criminals. In a model program, TASC clinicians used pretrial screening to assess

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DEFINING THE GOALS OF TREATMENT 600 _ 500 400 .= 300 _ oh lL Z 200 o CE Q 100 o oh G it O ~ LL] Cal can 150 o Z 1 00 cn 0 o Ct: 50 ~ CL UJ m at 250 _ a , 1~ 19251930 1940 1950 b O 1960 1970 1980 1988 YEAR l ~ -: --: I -. / -.: 2 ~ , - :--- - - -.- --: I::. : : - : - : -: : :.--- - - :-: - - -: -:-- :- - -: : -.--: -- :---. :-::: .-.-: :- ..................... -.-.-.-.-.-.-.- - - ... . .... . --- - - -.-- -. - .- ---.---.- - -- - - -.::--: -:: --- :-. .-- - - . - -- - - -- - - - - --- - --- - ---- -:- - -: -:- -:--- ::- - - --: .--: .- -..-..: i,:,: ., ... .-.-.i, : i: i: :-. i: -A -.---. : :.:.: : .-- :-: --: .-: - - - -- -- . - .- - - --- . - -.- - -: - -: : .-- :- - : -- :: -: -:.:. .:-:.:.:. .:.:. -:. - - - -:- .:-:. .-.-.:. --.:- .:- -:---:- - : : -:- -.-: - : :-- :-. i----:.---.-:.:: ~ -- -- -A So ------:~.-.:--.-- :: :: :: 1925 1930 1940 1950 1960 1970 1980 1988 YEAR 115 FIGURE 4-1 (a) Sentenced prisoners in state and federal institutions in the United States on December 31 of the years 1925-1988. Prison population data were compiled by a year-end census of prisoners held in custody in state and federal institutions. The 19 figures are advance estimates subject to revision. Data for 1925 through 1939 include sentenced prisonem in state and federal prisons and reformatories, whether committed for felonies or misdemeanors. Data for 1940 through 1970 include all adult felons serving sentences in state and federal institutions. Since 1971, the census has included all adults or youthful offenders sentenced to a state or federal correctional institution with maximum sentences of more than one year. Sources: Flanagan and Jamieson (1988:484~; Greenfeld (1989~. (b) Rate (per 100,000 resident population) of sentenced prisoners in state and federal institutions in the United States on December 31 of the years 194~1988. The rates for the period before 1980 are based on the civilian population, which is the resident population less the armed forces stationed in the United States. Since 1980, the rates are based on the total resident population provided By the Bureau of the Census. Sources: Flanagan and Jamieson (1988:485~; Greenfeld (1989~.

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DEFINING THE GOALS OF TREATMENT 121 seen as a similar lever for drug-abusing and drug-dependent employees. As a result of management concerns, union interest, and governmental actions, the role of employers in relation to drug treatment has become more extensive in the 197()s and 1980s than in previous years. Develop- ments in the past two decades have been institutionalized in two kinds of drug-related workplace activities: employee assistance programs (EAPs) and drug screening programs (DSPs). Although they have some common qualities, there is a clear disjunction in the purpose and operation of these two kinds of programs. Employee Assistance Programs Employee assistance programs, or EAPs, began in the 1960s and were originally associated with the alcohol treatment field, resulting from the growth of concern about "hidden" alcoholics in all social classes. Indeed, it is only in the past 20 years that experts and activists have driven home the idea that the great majority of alcohol-dependent and alcohol-abusing indi- viduals are not impoverished skid row inebriates but are spread throughout the working, middle, and upper classes, including the ranks of corporate ex- ecutives (Beauchamp, 1980; Moore and Gerstein, 1981; Roman and Blum, 1987, 1990; Institute of Medicine, 1990~. Today, EAPs serve a variety of management and employee benefit purposes, including the therapeutic management of drug problems. The original role of the EAP was to enable supervisors (through an aggressive policy of supervisory training) to identify suspicious job deteri- oration before the situation was hopeless and to engage in "constructive confrontation" originally called "constructive coercion" (~ice, 1966) of the employee regarding his or her alcohol problem. This confrontation would then be followed by referral to treatment and follow-up as appro- priate. Clearly, the goal of the EAP in this process was to return the deteriorating employee to satisfactory job performance; in pursuit of that goal, it provided training, assisted in confrontations, and made referrals. It was generally based in a central office and had its own credentialed specialists affiliated with the personnel or health department of a firm or union. EAPs are common in larger, unionized firms and agencies.4 About 26 million workers in private industry (31 percent of such workers; Bureau of Labor Statistics, 1989b) and 10 million public employees now have access 4A Bureau of Labor Statistics (1989b) survey indicated that EAPs are available to 4 percent of workers in establishments with less than 10 employees and 87 percent of workers in establish- ments with more than 5,000 employees. The same variation applies to drug screening programs, which are available to 1 percent of workers in sites with less than 10 employees and 68 percent of workers in establishments with more than 5,000 employees.

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122 TREATING DRUG PROBLEMS to an EAP. There has been steady growth: about 25 percent of Fortune 500 firms had EAPs in 1972, 57 percent had them in 1979, and virtually all such firms operate programs today. But EAPs have changed over time. Func- tions have been added (e.g., benefit management, brief counseling), and an industry of external EAP contractors has arisen. More significantly, the programs' original focus on alcoholism has broadened and now constitutes a larger social problem or "industrial social work" orientation: only one- third of a typical EAP's cases now involve alcohol or drug abuse, and the majority of cases are informal (and therefore confidential) "self-referrals" rather than formal supervisory referrals (Backer and O'Hara, 1988; Roman and Blum, 1990~. All of these trends have made EAPs more and more like an employee benefitone component of a total compensation package- and less and less like a management tool for maintaining desired levels of employee productivity on a day-to-day basis. Along with the reduced role of alcohol in EAP goals and activities, there has been increasing attention to drugs; this trend is in part the result of a generational change, as those entering the work force after 1970 increasingly were found to be consuming illicit drugs as well as alcohol. The rapid emergence of marijuana and cocaine use in the work force of the 1980s met the expansionary crest of spreading EAP services and explicit substance abuse insurance coverage for employees and their families, generating a rapid increase (but from a very low base) in drug treatment referrals. In particular, the attention of EAPs to mixed alcohol and cocaine problems coincided with the addition of drugs to the scope of the private tier of alcohol treatment providers, with widespread and often highly publicized offerings of combined treatment (chemical dependency) protocols. Typically, according to the corporate respondents surveyed by Roman and Blum (1990), about 4 percent of the employees in a firm providing an EAP consult the EAP in a given year. About 1.5 percent of employees specifically present a substance abuse problem, and in two-thirds of these cases, only alcohol, and not drugs, is clinically significant. These results correspond with a variety of data from individual firms reviewed by this committee during site visits. The bottom line is that about 0.5 percent of employees in an average EAP firm can be expected to consult the EAP (usually on a self-referred basis) for serious drug problems in a 12-month period. Applied to a work force of about 36 million individuals with access to an EAP, this suggests that about 180,000 candidates for referral to drug treatment may currently be seen by EAP counselors. Yet, as the changing role of EAPs suggests, the actual linkage of em- ployers to treatment has been much less substantial than the above figure suggests. Employer referrals or pressures play only a small role, based on the few data sets available on referral to private programs. According to

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DEFINING THE GOALS OF TREATMENT 123 counselor discharge evaluations supplied by programs subscribing to the Chemical Abuse/Addiction Treatment Outcome Registry follow-up system (Harrison and Hoffmann, 1988; Hof~nann and Harrison, 1988; these data mainly pertain to alcohol clients), the employer is mentioned as a pri- mary motivator for treatment admission by only one-sixteenth of inpatients and one-tenth of outpatients. In these private-tier, Midwestern, largely insurance-paid chemical dependency programs, greater numbers of both inpatients (one in seven) and outpatients (one in three) were reportedly motivated to seek treatment primarily by the courts most presumably as drinking/driving cases rather than by their employers. Drug Screening Programs The growth of drug screening programs (DSPs) has been a significant development of the 1980s, encouraged strongly by the federal government and most recently required of federal contractors by the Drug-Free Work- place Act of 1988 (P.L. 100-090, Title V, implemented by Executive Order 12564, 1989~. The growth of DSPs has been led by large companies, and there is increasing regulation by the states (Intergovernmental Health Pol- icy Project, 1989~. These programs are drug specific and rarely, if ever, test for alcohol. There are two fundamental kinds of DSPs: for employees and for job applicants. Most of the employee testing takes place at scheduled intervals (e.g., annual physical exams, prospective promotions to sensitive positions) or for probable cause rather than on a random basis, although random testing has attracted the most attention and~controversy. In 1988, about 16.6 million or one-fifth of private-industry employees worked in organizations with some kind of DSP. I\vo-thirds or 11 million of these employees were in establishments that have programs to test current employees, and 14.7 million were in workplaces that test applicants (bureau of Labor Statistics, l989b). Applicant testing is the lion's share of DSP activity: about 953,000 employees and 3.9 million job applicants were tested In the 12 months prior to the mid-1988 Bureau of Labor Statistics survey. About 84,000 employees (8.8 percent of those screened) and 466,000 applicants (11.9 percent of those screened) tested positive. Most of the positive tests yielded evidence of . .. ~ cocame or marijuana use. 5 these DSP results are not necessarily representative of overall employee or applicant drug consumption patterns. Most employee testing is based either on a strong suspicion of drug use (which greatly raises the likelihood of positive results) or the necessity to maintain a drug-free status in positions with particular safety hazards (which probably lowers that likelihood). In ad- dition, these results most likely underreport casual use (false negatives) because of conservative cut-of3: levels, limited test sensitivity, and intervals between periods of use; however, they may also include a number of false positives (American Medical Association Council of Scientific

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124 TREATING DRUG PROBLEMS How Employers View Drug Treatment Of the half-million positive DSP tests of job applicants, it is unknown how many if any lead to treatment. Me overwhelming rule, however, is that employers simply deny the job application when the test is positive. Drug screening programs thus are used far more frequently to keep people from working than to make them fit for it. As for employee testing, about 60,000 of the estimated 84,000 positive results occurred in firms with EAPs, which are more likely than employers without EAPs to consider treatment an appropriate response. Nevertheless, in one survey of 1,238 EAPs (Backer and O'Hara, 1988), virtually none reported that more than "~5 percent" of their clients entered treatment as a result of DSP activities, even though more than a third (35 percent) of the reporting EAPs were in firms or agencies with drug testing.6 The evidence, although thin, thus suggests that there are sharply fewer annual employer-related referrals to treatment than the combined figure from EAPs and DSPs of up to 264,000 potential cases. In the committee's judgment, a figure of around 50,000 annual employer referrals to treatment, which is to say, direct employer pressure to seek treatment, seems plausible. This number is roughly equal to the daily census of drug treatment clients inside jails and prisons; it is a fraction of the annual criminal justice referrals to treatment through TASC and related programs. Most of the employer referrals are to private-tier programs, about which research knowledge is especially sparse (see Chapter 5~. Until that base of knowledge Is improved. no better estimate is possible. cat ~ r- Despite the large productivity implications of drug abuse and depen- dengy, employers appear to use their potential leverage very gingerly with regard to treatment. They do voice great concern about the cost implica- tions of covering drug treatment under employer-sponsored health plans. This seeming disparity derives from two factors. One is the tendency to lose sight of drug treatment as such within the much larger pool of alcohol and psychiatric ("nervous and mental") benefit claims. The second factor is Affairs, 1987~. The errors are thus in different directions and of different magnitudes, and it is impossible to estimate the net resulting bias. 6The comparable figure in the Bureau of Labor Statistics sample was that 45 percent of EAPs were in DSP firms. This comparison is noted because the Backer and O'Hara survey needs to be viewed cautiously; the survey response rate was 16.2 percent, and the sample of EAPs was not selected from an enumerated list or sampling framework. The U.S. General Accounting Once (1988) reviewed 10 other surveys of employers from 1985 to 1989. None of them were representative samples, and most had low return rates similar to the Backer and O'Hara survey. Most companies indicated a willingness to refer current employees with positive drug screening results to a rehabilitation program on a case-by-case basis, but there was no indication how often referral took place in practice. In 439 EAPs surveyed by Blum and Roman in 198~1985, those with DSPs reported the same rate of drug-related referrals as those without screening programs.

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DEFINING THE GOALS OF TREATMENT 125 the high growth rate in payouts for inpatient care for drug abuse diagnoses that are attributable not to employees but to their covered dependents, particularly adolescent girls. These issues are assessed further in Chapter 8, but their prominence strongly reinforces the impression that employers view drug treatment more as part of the problem of high employee benefit costs than as part of the solution to a pervasive productivity problem. AMBIVALENCE AND THE SPECTRUM OF RECOVERY Even drug consumers who are badly impaired or severely pressed by legal or other problems are often ambivalent about seeking treatment. They may yield in the end only because pressure from family members, the law, deteriorated health, psychological stress, or a combination of such factors becomes too intense to deny. They may also find themselves impelled to seek treatment finally because attempts to relieve the pressure through other means, such as unassisted self-control, have proven futile. Ambivalence toward treatment has several sources. First, it is always necessary to remember that the population involved like the drug"; they consume. Drugs "work" for them, providing psychological and physical effects they have learned to value. Beyond the drug effects as such lie personal satisfactions for drug consumers in their ability to acquire and use drugs, both of which require a certain amount of practical and ritual competence (Preble and Casey, 1972; Johnson et al., 1985~. It is easy, moreover, for the heavy consumer to mistake the satisfaction of drug wants and needs for the satisfaction of most (if not all) other wants and needs. This mistake is readily compounded because sustained drug experience may make an individual quite adept at meeting drug-specific requirements (e.g., knowing which drugs to buy and from whom, how to get the most effect from a drug) and less capable of satisfying other requirements, such as holding down a job. In addition, there is moral and logistical support for drug behavior to be found among other drug consumers, who may be close friends and family members. Their moral support for drugs may well extend to active disapproval of treatment (Eldred and Washington, 1976~. Finally, most forms of drug treatment, if implemented according to best clinical practice, are rigorous. These programs impose environmental schedules and controls and require a substantial amount of emotional work and behavioral change on the part of the client. Their requirements range from such logistical conditions as restrictions on mobility, keeping appointments for psychotherapy, and urine testing to more deep-seated issues such as clinical frankness and movement toward behavioral and emotional maturity. Unfortunately, clinical rigor has probably diminished in recent years as declining resources cut deeply into program operating capabilities. For example, programs that formerly used once-a-week urine

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126 TREATING DRUG PROBLEMS testing have cut back in many cases to monthly tests, in compliance with minimum federal regulations. Psychotherapy and other service hours have typically been reduced by half or more from earlier levels (Hubbard et al., 1989~. Nevertheless, even at reduced levels of program rigor, drug consumers' ambivalence about participating in clinical procedures or program activities may lead to their breaking off the admission process before it is com- pleted. Ambivalence generally continues during the first days and weeks of treatment exposure, presenting a stubborn challenge to clinicians. Where admission pressures such as threats to personal safety, legal jeopardy, health problems, or other motivational sources are not especially durable and the individual's goal of immediate relief is not accompanied by the need to protect positive assets or by a strong desire for longer term relief from drug seeking and its associated life circumstances, it is often difficult to overcome a person's reluctance to comply with demanding clinical re- quirements. Remitting pressures and continuing ambivalence undoubtedly contribute appreciably to the rapid early attrition curves seen in many drug treatment programs. These judgments about the relation of motivation and attrition are difficult to prove or quantify with available research evidence. All mea- surements that correlate with early treatment dropout do so rather weakly (Hubbard et al., 1989~. This weakness may be the result of imprecision in measuring the motives for seeking treatment and imprecision inherent in the dichotomies typically employed in client surveys, such as self-referral versus other-referral, on probation or parole versus not on probation or pa- role, and no versus any "perceived legal pressure." It may also be the case that a more general quotient or index of treatment motivation needs to be developed, taking into account the balance between severity of problems, attractiveness of assets in jeopardy, and features of the client's extended individual history of drug experience. Measurement problems aside, it is clear that initial motivation is but one element in a constellation of factors affecting the duration of treatment. Some of the other elements that have been studied, including qualities of program staff and specific treatment procedures, are reviewed in Chapter 5. Full, Partial, and Nonrecovery from Drug Problems An individual's initial motivation with respect to changes in his or her drug consumption varies from a desire for full recovery aiming to achieve a lifetime of continuous abstinence through more modest intentions, which can be called partial recovery, to not seeking recovery at all. The desire for lifelong abstinence is straightforward and easy to understand, but it is far from universal among clients in treatment. It is most likely to be found

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DEFINING THE GOALS OF TREATMENT 127 among those for whom the retention of valuable personal assets hinges on abstinence, forming a powerful counterweight to the attractions of drugs. More affluent and socially conventional clients often have a comfortable home, a good job, respectability, and an intact non-drug-using family at the time of admission, and these assets serve as incentives that support abstinent motivation. Less advantaged clients, those who are without most or all of these attributes or without evident prospects for securing them (even though they may greatly desire such things), have few preadmission assets. Indeed, it may be that the only resources these individuals possess, the threat of whose loss acts as an incentive, are their lives and their rights as citizens- even as second-class citizens from whom certain fundamental rights have already been withheld, as in the case of parolees. In other words, for socially disadvantaged individuals who are heavily involved in drug use and whose positive personal assets are limited, avoiding a long stretch in prison may be the only motivational counterweight strong enough, at the outset, to balance the lure of easily available drugs. The ethical and civil rights implications of this inequality between the well-off and the disadvantaged are troubling; nevertheless, this description accurately depicts the current state of affairs. Clients may formulate exterior motives for entering treatment as "to get [someone] off my case." External pushes are usually allied to some degree with positive pulls or motivations to change. The positive motives are often not strong enough in themselves to initiate or sustain compliance with treatment, but reinforcement through external pushes into treatment and therapeutic pressure within treatment may be effective in doing so. Clients often enter treatment as a self-conscious strategy to achieve partial recovery. That is, their purpose is to use treatment to help them gain control over their drug behavior not to extinguish it entirely but to enable them subsequently to moderate it, perhaps for the first time in many years (e.g., to reduce their use to the manageable level they may have attained during an earlier, happier period of their drug-using careers). The purpose of these clients may be, for example, to keep daily drug use down to a clinical prescription (perhaps methadone, a tranquilizer, or a mood elevator) plus some drinks and an occasional "hit" of marijuana, methamphetamine, or some other "treat." Most important to this kind of applicant or client is to avoid taking the major drug of dependence (usually cocaine or heroin) or, if a "slip" happens in a moment of weakness, to have some protection and instantly available help against falling back into a full-blown, full-time habit (Wesson and Smith, 1985~. These are users for whom treatment is a crutch, but one that produces both individual and social benefits. The challenge they offer to the quality of counseling and clinical acumen in a program is to make the crutch perform well, to satisfy and at the same time try to upgrade their recovery aims.

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128 TREATING DRUG PROBLEMS In contrast to the motive toward partial recovery, some clients have no wish at all to modify their drug consumption but seek program admission only to falsely certify such intentions in the eyes of family members or criminal justice agents (or both). How programs respond to these "bad attitudes" varies. Some programs work hard to discover and stop any de- ception on the part of clients and to confront them early on with the choice either of working to reform these attitudes and their accompanying behavior or of leaving treatment. Other programs subscribe to the philosophy that drug use and related attitudes such as deception (including self-deception or denial) are the fundamental clinical problems for which the person was admitted and that, for such cases, staying in treatment represents an im- provement in health status, even if the improvement is small. Therefore, it would be impermissible to deny these individuals further treatment. It is a truism among clinicians, however, that such persons are probably heading for even deeper trouble, and later many of them seek treatment again with a different attitude. Setting Realistic Goals Drug problems that are serious enough to need treatment are usually chronic and relapsing in nature generally, they are embedded in several ways in the client's life, they have built up over time, and they have often inscribed permanent social, emotional, and physical scars. Recovery from chronic, relapsing conditions takes time and requires much effort from an individual; how much the client wants to work toward recovery undoubtedly makes a difference in treatment. But people who seek drug treatment vary in what they want to gain and in who else is involved. For clients seeking admission, treatment is the solution to a problem or problems too serious to ignore and too large to handle without help. Full recovery from dependence, including complete abstinence from drug use, may not be necessary to solve the problem that led them to treatment, although it may be the answer, or part of the answer, to even larger problems that an individual seeking treatment does not acknowledge or yet want to solve. All of these elements affect how much effort the prospective client is willing to put into the recovery process. Drug treatment clinicians have devised ways to respond to these varying client features and have incorporated these methods into program policies and goals. Program policies are not all dry abstractions and pious senti- ments; rather, they are rules of thumb for selecting clients for admission, dispensing discipline or extra attention, or deciding on discharge. Every program admits applicants to some degree according to its reading of an applicant's motives and situation, including the role of third parties such as the law and third-party payers. Programs vary in how eager they are

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DEFINING THE GOALS OF TREATMENT 129 to accept or avoid the harder cases, how intensively they are willing (or able) to work to treat the most difficult problem clients, and how heavily or swiftly or carefully they impose sanctions for noncompliance with the treatment plan. Abstinence from illicit drug consumption is the central clinical goal of every kind of drug treatment, but it is not the complete goal. Clinicians also want their clients to stay out of jail and away from criminal activities, to be physically healthy, to adopt productive roles in family or occupational settings, to feel comfortable and happy with themselves, to avoid abuse of or dependence on alcohol. Full recovery in all of these senses can be realistically envisioned in some fraction of cases a fraction that depends in part on the kind of population from which the program recruits its clients. But full recovery is not a realistic goal for other individuals, and those others make up the majority of admissions to most drug programs. For another fraction of applicants, even partial recovery as a result of the particular treatment episode is unlikely, although a period in treatment may plant or nurture the seeds of more serious efforts toward treatment and recovery in the future. In summary, the pragmatic objectives of treatment in most cases are modest: to reduce illicit drug consumption, especially of the primary drug of abuse, by a large percentage perhaps to nothing for an extended period relative to the consumption one could expect in the absence of treatment; to reduce the intensity of other criminal activity if present; to permit the responsible fulfillment of family roles; to help raise employment or educational levels if the client so desires and the program has the resources available for such an effort; and to make the client less miserable and more comfortable physically and mentally. These goals are incremental: instead of absolute success and failure, there are degrees of improvement. In light of the substantial losses to society resulting from active drug abuse and dependence, the committee considers a quantitative reduction in illicit drug consumption and the problems that accompany it for an individual client to be a socially and personally valuable result. An extended abstinence, even if punctuated by slips and short relapses, is beneficial in itself and may serve as a critical intermediate step toward lifetime abstinence and recovery. A useful shorthand for this pragmatic goal is that drug treatment strives to initiate, accelerate, and help sustain the recovery process. Treatment goals may be influenced or guided by theoretical contem- plation or rigorous induction, but they are typically selected and ordered by a complex process of social trial, error, and negotiation. Goals also vary because individual problems vary from client to client. Some clients' drug abuse or dependence is entangled in a chaotic life of violent criminal acts, ruptured family relationships, illiteracy, and psychological disturbance. For

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130 TREATING DRUG PROBLEMS other individuals, drug abuse or dependence is a deviation from a pattern of conventional social successes and advantages. Treatment goals also vary because social concerns with different elements of drug problems differ over time and across institutional settings. Programs have different orientations that affect the kinds of clients they recruit and the depth of their commitment to the "total client." A program may be oriented primarily toward an intensive short-term (e.g., four- to six-week) treatment protocol, viewing its task only as ensuring that the first steps toward recovery are taken, leaving the client, family, and other interested parties to complete the recovery process. A program that for the most part recruits socially advantaged individuals will not need to provide or help the client find vocational. educational. housing. welfare. or primary medical services. A program with a longer term treatment protocol may view its primary responsibilities more comprehensivelyto deal not only with the initial steps toward recovery but also with any other aspects of the client's cir- cumstances that may increase his or her vulnerability to relapse. If these negative circumstantial aspects are prominent, then that program sets itself a much more challenging task than the program whose clients have few problems other than drug-seeking behavior with which to contend. Of- ten, a program must develop channels to vocational, educational, housing, welfare, psychiatric, or primary medical services or else gain the resources needed to offer the necessary services itself, particularly for clients who are so disorganized that they have to have everything packaged together in one place. Such programs are prepared to view joblessness, psycho- logical depression, or homelessness as part of the diagnosis they need to treat. That kind of perspective does not mean that these clinicians believe that joblessness, psychological depression, or homelessness are universal causes of drug problems or that the country must deal with unemployment, melancholy, and housing problems nationwide in order to help any indi- vidual client. It does, however, make these programs intrinsically more expensive to administer. The justification for the higher level of resources expended per client hinges on the prevailing norms surrounding assistance to the disadvantaged and the effectiveness with which programs are able to employ these resources to produce better recovery outcomes. , , a, CONCLUSION The picture of drug treatment goals that results from this chapter's analysis is not simple, but it has a certain coherence. That coherence resides in the principle that what should be expected from treatment is relative relative to who is being treated and to how severe his or her

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DEFINING THE GOAI~i OF TREATMENT 131 problems are, and relative in that success should be viewed as a matter of more or less rather than all or none. ~ define a reasonable set of treatment goals, it is necessary to consider certain characteristics of those being treated: depth of drug dependence, extensiveness of criminal activity, state of physical health, history of em- ployment, status of family support, what specific problems precipitated treatment, who besides the individual client has become concerned with what he or she is doing, and the seriousness of the client's intentions. The goals of treatment are to address and significantly improve these charac- teristics; the effectiveness of treatment is gauged by how much it improves them compared with what would probably occur without treatment. In general, the primary goals of treatment have centered on reducing heroin or cocaine intake, predatory crime, and client death rates; at a secondary level, they involve marijuana or alcohol intake, unemployment or poor job performance, and lack of education. Improving family conditions and psychological well-being are sometimes viewed as ends in themselves, at other times as side effects of reaching primary goals, and at still other times as important prerequisites to reaching primary goals. More is known about the primary than about the secondary issues. For example, predatory criminal behavior persists even in the teeth of extensive arrest and imprisonment. For this reason, criminal justice agencies have frequently turned to drug treatment programs for help in dealing with the drug-dependent criminals under their supervision in hopes of slowing down the increasing burden of recidivism and overcrowding. Employers, on the other hand, are much more committed to the use of drug testing, the most recent and rapidly growing employer program in this connection, to keep individuals with drug problems from entering the work force rather than to push toward recovery those who are already in it. This agenda may explain the fact that increasing drug treatment costs seem to them far more a threat to be eliminated than a productivity opportunity to be seized, an issue to which the committee turns in Chapter 8. Because recovery clearly is possible and because most people enter treatment in search of it, albeit under pressure and with very mixed and confused motives, the committee believes that any worthwhile treatment program or method should be able to demonstrate that it has accelerated recovery among most of its clientele. However, rapid and full recovery is sufficiently unusual outside of treatment that it should not be viewed as the sole measure of treatment success. Partial recovery is better than no recovery. There is a real difference between hundreds or thousands of illegal and unhealthy acts over a period of time and a handful or even scores of such acts, and that difference should not be ignored when programs are called on to account for their clients' behavior.