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OCR for page 105
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
OCR for page 106
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
OCR for page 107
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 drugs—or,
more stringently, end it altogether;
· substantially reduce—or end altogether violent and acquisitive
crimes by the treated individual against others;
· substantially reduce—or 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
OCR for page 108
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 dignity—or destigmatization of
the afflicted individual (Wiener, 1981; Institute of Medicine, 1990; Ro-
man and Blum, 1990~. More recently, the fear of harmful or criminal
behavior—including 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.
OCR for page 109
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
less—or 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.
OCR for page 110
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
OCR for page 111
DEFINING THE GOALS OF TREATMENT
111
primarily when there is a negative or threatening situation to be alleviated
in any one—or more—of 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.
OCR for page 112
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.
OCR for page 113
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
OCR for page 114
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
OCR for page 115
DEFINING THE GOALS OF TREATMENT
600 _
500
400
.= 300 _
oh
lL
Z 200
o
CE
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o
oh
G
it
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~ LL]
Cal can 150
o
Z ° 1 00
cn 0
o Ct: 50
~ CL
UJ
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at
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a
, 1~
19251930 1940 1950
b
O
1960 1970 1980 1988
YEAR
l
~ -: --:
I -.
/ -.: 2
~ , - :--- - - -.- --:
I::.
: : - : - : -: : :.--- - - :-: - - -: -:-- :- - -: : -.--: -- :---. :-::: .-.-: :-
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· .-- - - . - -- - - -- - - - - --- - --- - ---- -:- - -: -:- -:--- ::- - - --: .--:
· .- -..-..: i,:,: ., ... .-.-.i, : i: i: :-. i: -A -.---.
: :.:.: : .-- :-: --: .-: - - - -- -- . - .- - - --- . - -.- - -: - -:
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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~.
OCR for page 121
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.
OCR for page 122
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 benefit—one 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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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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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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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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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 comprehensively—to 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.
Representative terms from entire chapter:
criminal justice
