The cost-effectiveness of prison-based drug treatment.

Author:Petersen, Cheryl Bowser

Save money by spending money on prison-based drug treatment--this sounds too good to be true. However, according to the first and only study on the cost-effectiveness of prison-based drug treatment, conducted by a Brandeis-Brown University research team, the drug treatment did just that. Not only did it reduce recidivism in the experimental group, it also saved considerable money for the Connecticut Department of Corrections (DOC). Furthermore, although the study only measured direct savings to the DOC, it was clear that there was also tremendous indirect, systemwide savings. This means the widespread savings were even more than calculated.

Could the research methodology be unsound and, therefore, the results wrong? The study employed a sophisticated multistage sampling design with experimental and control groups. To ensure data accuracy, the data collectors both held doctorates; one was a full professor in her own right and the other was a post-doctoral student. (This contrasts with the typical university research that uses graduate student interns to collect data.) The analysis employed a multivariate statistical model that controlled for many factors that would impact recidivism aside from the treatment. This included variables such as age and criminal history. The cost portion of the study was designed and analyzed by Donald Shepard, an internationally known cost-economist with a doctorate from Harvard. Thus, from a methodological perspective, the resulting findings are sound.

Therefore, what importance does the result of this study have for practitioners? One of the most important findings for practitioners is that variations in treatment protocol increased (or decreased) recidivism and cost savings. These variations are discussed at length in this article, and since the treatment program used in Connecticut is much like treatment programs used in many state prison systems, the modifications suggested by this study also are likely to work its cost-effectiveness magic in other states as well.

Description of the Program

The Connecticut drug treatment program offers four distinct levels of treatment intensity, referred to as tiers.

Tier 1: Basic substance abuse education. This lowest level consists of six group substance abuse education sessions and a minimum of one fellowship meeting. This is the least costly treatment resource. It is mandatory for all inmates with any level of drug treatment need.

Tier 2: Intensive outpatient. Participants remain in the general population and participate, on sort of an outpatient basis. in the program. Participation is three times a week for 10 weeks.

Tier 3: Daycare. While still remaining in general population, participants spend the entire day in "treatment" modalities. The program lasts 16 weeks.

Tier 4: Residential treatment. For six months, participants are separated from the general population and housed in a residential modified therapeutic community setting with full-time programming. Within this milieu, inmates are encouraged to practice and learn the material presented in the curriculum.

The DOC tries to ensure that the treatment provided at each tier level is consistent from one facility to another. For example, there are depart-mentwide written standards that guide program delivery. Furthermore, the Addiction Services Bureau conducts periodic audits at each facility to ensure conformity in delivery and to identify and address potential problems. Despite these efforts, however, inmate focus groups and staff interviews suggest that some variability in quality and delivery across institutions remains. This variability has a negative impact on the cost-effectiveness of programs.

Another feature of the Connecticut program is that inmate motivation to change is measured via self-report data during intake into the system. This is important because the literature confirms a link between intrinsic motivation and success. For example. Gideon (2009) found that self-motivation increased the likelihood of success in adult prison-based drug treatment programs. Smith and Winters (2005) also found that personal, intrinsic motivation had a positive impact on the success of residential drug treatment for adolescents. Similarly, Curry et al. (1990) found that smokers (also. considered to be substance abusers. albeit legal abusers) with intrinsic motivation were more likely to quit smoking than smokers with extrinsic motivation. This and other research supports the notion that the cost-effectiveness of drug treatment is affected by client motivation to change.

However, as many researchers know, social desirability bias can be a significant threat to the validity of self-report data (Maxfield and Babbie. 2008). This is especially true in prison populations in which there is strong motivation for inmates to convince prison officials of their desire to rehabilitate so that they garner benefits and early parole. Therefore, motivation for change also was assessed more directly through actual behavior--inmates were required to actively campaign to get into the higher tiers of treatment. The research team initially believed that this willingness to assertively pursue needed treatment was a surrogate measure for motivation, but analysis of program completer versus drop-out data suggests that this assumption was not true.

An additional component of the Connecticut treatment program is the use of peer mentors, which is similar to the successful Alcoholics Anonymous program's use of sponsors (who are peer mentors). In the Connecticut program, peer mentors must have successfully graduated from the specific tier program at which they want to mentor. In addition, they must maintain a good disciplinary profile, continue successfully with their own treatment needs and be recommended as a mentor by institutional staff. Once selected, mentors are provided with a written job description and expectations. They attend an orientation program and participate in ongoing training. Mentors are expected to participate in a random, weekly urinalysis. They are closely supervised by professional treatment staff and are given written employee evaluations by their supervising therapist. Mentors who fail to obtain a rating of "good" or "excellent" are terminated from the program.

The success of peer mentoring/sponsoring is supported in the empirical research. For example, in a longitudinal, randomized clinical trial, Rowe et al. (2007) found that patients in the experimental group (i.e., the group working with peer mentors) showed significantly...

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