Treating Drug Problems Volume 1 (1990) / Chapter Skim
Currently Skimming:
4 Defining the Goals of Treatment
4 Defining the Goals of Treatment
Pages 105-131
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 105... ...
Such assessments are in turn crucial 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 problem 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.
|
From page 106... ...
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.
|
From page 107... ...
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, longevity, and psychological well-being; · reduce specific drug injection practices and hazardous sexual behaviors, 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)
|
From page 108... ...
Family members 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 individuals 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.
|
From page 109... ...
What are the actual and the optimal goals of drug treatment and the criminal justice system? What are the supporting relationships between them?
|
From page 110... ...
; · alcohol use (use during past 30 days, recent dependence/abuse symptoms, lifetime use, length and date of last abstinence, lifetime overdoses 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)
|
From page 111... ...
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.
|
From page 112... ...
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.
|
From page 113... ...
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?
|
From page 114... ...
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.
|
From page 115... ...
(b) Rate (per 100,000 resident population)
|
From page 116... ...
Criminal justice referrals to methadone programs in the sample were rare too rare to permit reliable statistical results but a substantial percentage (31 percent) of those admitted to outpatient nonmethadone and residential therapeutic community programs in the TOPS project were referred by criminal justice agencies, largely TASC programs.
|
From page 117... ...
The experience with community-based treatment during the 1970s was certainly favorable. When neither the treatment programs nor the criminal justice system was overwhelmed by cases, the deals struck between defendants, the courts, and the programs appear to have had clinically benign or positive effects; clients so acquired did at least as well in treatment as clients entering as a result of other forms of pressure.
|
From page 118... ...
found that the rate of rearrest within three years of release was virtually the same for individuals serving as little as six months as it was for those serving as much as five years. Only the 4 percent of prison releasees who had served terms longer than five years almost all of whom were convicted murderers, rapists, and armed robbers with multiple convictions had a lower rate of rearrest (by about 14 percentage points)
|
From page 119... ...
The most important reason to consider these or related schemes to force more criminal justice clients into drug treatment is not that coercion may improve the results of treatment but that treatment may improve the rather dismal record of plain coercion particularly imprisonment in reducing the level of intensively criminal, antisocial, and drug-dependent behavior that ensues when the coercive grip is relaxed. In fact, getting more criminal justice clients into treatment could improve the results of criminal justice sanctions even if it actually diminished the average effectiveness of treatment.
|
From page 120... ...
In view of the unrelenting growth of criminal justice populations, which threatens to swamp prison capacity and adjudication processes alike, any increase in these systems' ability to pressure people to enter or comply with treatment seems unlikely. Rather, increasing treatment capacity and improving the quality of treatment programs may be a way to keep the justice system situation from becoming even worse.
|
From page 121... ...
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 individuals are not impoverished skid row inebriates but are spread throughout the working, middle, and upper classes, including the ranks of corporate executives (Beauchamp, 1980; Moore and Gerstein, 1981; Roman and Blum, 1987, 1990; Institute of Medicine, 1990~.
|
From page 122... ...
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)
|
From page 123... ...
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)
|
From page 124... ...
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~.
|
From page 125... ...
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.
|
From page 126... ...
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 requirements. Remitting pressures and continuing ambivalence undoubtedly contribute appreciably to the rapid early attrition curves seen in many drug treatment programs.
|
From page 127... ...
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)
|
From page 128... ...
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.
|
From page 129... ...
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.
|
From page 130... ...
, , 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
|
From page 131... ...
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.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.