Rural Issues in Alcohol and Other Drug Abuse Treatment
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Addict or not, there is an urgent need to spread the message of how dangerous it is to use alcohol and other drugs (AOD). An unwitting alliance of distilleries, tobacco companies, pharmaceutical manufacturers, advertising agencies, television, movies, and others purport a mythical lifestyle where the hip, slick, cool, and beautiful people live better through chemistry. In reality, those trying to live out this fantasy have entered a lifestyle whose downward spiral can only lead to destruction. The "king for a day" progresses to unemployment, family breakup, domestic violence, date rape, and prison.
Incarceration provides a population whose use of AOD ranges from recreational to hard core addiction. Traditionally, treatment has been the primary programing option for the Iowa Department of Corrections. But, in over 20 years of combined corrections experience, the writers of this paper learned that a monolithic approach to AOD use cannot effectively address this wide range of use. A new and improved treatment program is not seen as the answer, as there are many quality programs available. Besides, treatment programming is not always indicated.
Few would disagree that inmates are difficult to counsel and love to play games. So, prior to treatment, the staff sorts out those who would disrupt the treatment process. Then, after treatment, the staff holds the inmates feet to the fire to ensure that they follow through with their treatment goals.
This is the foundation and uniqueness of Project TEA (Treatment, Education, and Awareness). Using a multilevel approach, the staff uses awareness and education to burst the king's bubble, to get the addict to the point where he or she is ready to confront addiction head on. Project TEA also sabotages a ploy the criminal addict counts on: Get staff to give up by being as nasty as possible, then blame the staff for giving up.
The pretreatment levels of awareness and education can function as a springboard to recovery, an elephants' graveyard for those unwilling to change, or a place for inmates who lie and finagle their way through treatment. But treatment counselors will persist no matter how many times inmates lie or slam doors in their faces. They will help participants to develop an agenda and network with community resources. Then it will be up to the participants to weave their own safety nets from the skills learned in treatment. Staff will be watching for those who do not follow through; they will still be there when they slip and fall and come back. Then the process can begin again.
Licensing was just the tip of the iceberg. In 20 years of combined corrections experience, the staff had learned that (1) inmates were sent unnecessarily to treatment; (2) even with prior treatment experiences, some inmates were not ready for treatment; and (3) some inmates just wanted their tickets punched for a quick trip out. To meet these varied needs, the staff created a three-tiered program comprised of treatment, education, and awareness.
The goal of treatment is to engage the participant in activities that support recovery through an abstinent, comfortable, balanced, responsible, and fulfilling lifestyle. As a prelude to treatment, awareness and education provide programming opportunities for the nonaddict and prepare addicts for their treatment experience. The purpose of awareness is to establish a foundation of common knowledge. This enables participants to recognize and discuss the addiction process and its consequences. Education strives to reactivate the participants' thinking processes, helping them discover the link between alcohol and other drugs (AOD) use and its consequences.
The objectives of awareness and education are threefold: (1) to prepare an addict to enter a recovery program and gain maximum treatment benefit, (2) to provide the nonaddict with a hard look at the reality of addiction, and (3) to provide "recycling centers" for those whose denial is a barrier to a fulfilling treatment experience.
In addition, AOD has a significant impact on the criminal justice system. According to the Bureau of Justice Statistics (BJS), 77.7 percent of jail inmates and 79.6 percent of State prisoners have used AOD at some point in their lives. A 1989 study by the BJS found that 27 percent of jail inmates were under the influence of a drug at the time they committed their crimes, and 13 percent of convicted jail inmates perpetrated their crimes in order to obtain money for drugs. BJS also found that 36 percent of the victims of violent crime believed their assailants were under the influence of AOD (Drugs and Crime Facts, 1991).
Today our Nation's correctional facilities are bursting at the seams. Iowa's Department of Corrections is no exception. It currently operates at approximately 1,350 inmates over capacity. Many in corrections agree that current overcrowding can be directly attributed to addicted offenders (Valle 1991).
The foregoing is not meant to imply a causal relationship between the use of AOD and criminal behavior. It has been estimated that some 70 percent of Americans use alcohol, and the vast majority do not run out and perpetrate crimes. In 1985, Dr. Bernard Gropper of the National Institute of Justice reported that use of AOD was not necessarily the primary or only cause of violent crime, although it did seem to be a characteristic of violent offenders (Zawistowski 1991).
Despite this characteristic connection, only 15 percent of incarcerated addicts receive any type of chemical dependency counseling (Valle 1991). This is in spite of evidence reported by Dr. Gropper that reduced drug use translates into reduced levels of criminal activity (Zawistowski 1991).
The ISP sent inmates to drug treatment programs at other institutions for many years. Inmates often related that they only sought treatment to satisfy a request by the Iowa Board of Parole. Many of these inmates had been convicted on drug-related charges and the parole board wanted their use of AODs addressed prior to early release. After completing a treatment program, inmates frequently returned to the ISP stating it was a waste of time, even though their records showed many problems with AOD.
We suspected that the intense level of programming required by licensure and the willingness of inmates to enter treatment resulted in premature referrals. We felt that, of the 96 percent identified as having AOD problems, perhaps 10 percent were ready to enter treatment. But what about the other 86 percent? Programming was needed, but not always treatment.
We found ourselves in a unique situation. The ISP is the State's only facility housing maximum, medium, and minimum security inmates spread out over four locations. Its inmates serve sentences ranging from 1 year to life.
Our task became clear: Develop a service delivery strategy providing new programming alternatives that address AOD problems on several levels, with each level focusing on particular needs and building on the previous level(s).
The primary question became: At what levels should we provide these programming alternatives?
Historically, the ISP had what could best be described as a study group. The study group brought about two important realizations: (1) it is possible to foster an understanding of and discuss the complexities surrounding addiction, and (2) participants can be encouraged to reflect upon and share their feelings regarding the use of AOD.
Staff envisioned combining our study group experience with the treatment accomplishments of our colleagues at other prisons. This would maximize our goal of providing programming alternatives to our three target populations: (1) recreational users, (2) habitual users, and (3) addicts.
The task became to develop a program where all three groups could begin. The first level of programming would tell the recreational user, "We'll be here," and would advance the habitual user and the addict to the next level. The second level would be a critical one for both staff and inmate. This level would sort out the participants by evaluating (1) the user's level of reliance on AOD, (2) ability to identify the negative consequences caused by AOD in his or her life, and (3) level of motivation in seeking treatment.
Again, we would need to say, "We'll be here" to both those who had developed the momentum to advance in their treatment and those who had not. In the past, too many inmates were dropped from treatment because they were not considered teachable. Our goal is to persist with such tough cases and have them repeat the first two levels. Perhaps the second time around, or after subsequent rounds if needed, the individual will develop the insight, motivation, or fortitude to make it through treatment.
It is important for the addict, and the criminal addict in particular, to know that the therapeutic community will never give up. A naive and unconditional, "Do what you will" should be replaced with, "We're here when vou are ready."
There is a real danger that if dropped with no options, the addict criminal will say, "See, they don't care" to justify use of AOD and criminal activity. Our approach is designed to have three benefits: (1) to continue some level of programming, no matter what, to make clear that "We'll be here," (2) to better utilize scarce resources by repeating awareness and education, and (3) to enhance the quality of treatment by having motivated participants.
The awareness and education levels of the program are not licensed by the Division of Substance Abuse. Hence, compared to the treatment program, these levels do not need to be as intense and are not subject to the same level of confidentiality as is required for treatment. This allows greater flexibility in program design.
The study group experience at the ISP demonstrated that audiovisual programs sparked discussion and often prompted sharing of personal experiences. Recognition reactions to the video content were also regularly observed. The entire relaxed atmosphere of the study group removed much of the anxiety associated with intense treatment programs. Participation at this level also minimized the stigma of being in a treatment program.
A weakness of the study group is its lack of structure. The nondirected approach seemed too haphazard, which reduced its effectiveness. To minimize this weakness, staff sought to develop a curriculum for each of the two levels. Fourteen topics were identified for awareness and 26 for education. Each topic would be covered in an individual session with the theme presented by an appropriate video.
The Iowa Substance Abuse Information Center (ISAIC) serves as the State's substance abuse information clearinghouse and has an extensive collection of quality materials. The staff has developed an excellent working relationship with ISAIC, which has expressed its commitment to helping the ISP find materials related to substance abuse in the corrections setting. The ISAIC collection also includes culturally sensitive videos which add yet another dimension to the programing.
The entry level of the program is awareness. Addicts are often unaware they are addicted; all they know for sure is that "life stinks and they are hurting."
For nonaddicts, awareness is a form of prevention, in that it aids recreational users in evaluating their use/ reliance on AOD in social situations and helps them to cope. The fact that AODs do not yet present them with major life problems does not make these users immune to addiction.
It is felt that awareness information benefits the addict as well. As Dr. Fritz Pearls put it, "Nothing changes until it becomes what it is." If you need to fix something, you better know what is broken.
Awareness is a cognitive process designed to build an information base. "Doing the legwork" may not be full of glitz and glamour, but it lays the foundation for a solid recovery. With 96 percent of the inmates at the penitentiary using AOD, it is felt that all need to recognize the potential for addiction. Five general areas are addressed during awareness: (1) the nature of addiction, (2)biopsychosocial factors, (3) 1, role of denial. 4) the self destructive lifestyle associated with addiction, and (5) the hope of recovery.
The inmate population does not fit neatly into the categories of addict and nonaddict. For habitual users the use of alcohol and other drug;. is not yet mandatory for them to cope or to make social situations satisfying or meaningful—it just makes them a lot more fun. Such individuals now teeter on the brink of addiction. Education strives to make habitual users aware of their vulnerabilities and to reach these inmates on an effective level as a form of intervention.
To accomplish this, education forces participants to take a serious look at the consequences of their AOD use. Habitual users need to see that coming to prison is not simply a part of some game between them and the criminal justice system; that their AOD use sends out ripples on a pond and affects those around them; and that, to those affected, these ripples are more like tidal waves. Though not yet obsessed with AOD, these habitual users can thus reassess their use before it crosses the line into uncontrolled abuse and addiction. For the addict, education challenges their denial; they begin to feel a need for help.
Many will drop out of programming after completing awareness and/or education feeling they have obtained maximum benefit. Some will be more cautious in their use of AOD, avoiding the trap of addiction. Others will simply present their gold stars to release authorities. Many will bury their heads deeper in the sand and cling to their denial, but hopefully not as easily as before. For these inmates, we'll be there should they want to try again. But, tor the select few, the sojourn through awareness and education leads to that moment of truth when they acknowledge their addictions and seek appropriate treatment. For these individuals, treatrnent represents the hope for a new beginning.
The goal of treatment is to have the participant engage in activities that will bring about identified changes in behavior. A guiding question is, "What are you going to do differently when confronted with challenges that, in the past, have led to using AOD?"
The First TaskProject TEA presents recovery as a two-edged sword against AOD use. One edge represents abstinence and the other represents changes in total behavior. The objectives of abstinence are (1) to understand that one can never use any mood-altering substance, and (2) to associate with a group whose goal is to support abstinence, such as Alcoholics Anonymous (AA).
Abstinence alone will not produce recovery. AA calls it "white knuckling it." These individuals still think and act like addicts; they just do not use AOD. They are simply biding their time until they use drugs again.
For recovery to be fulfilling, it will also require changes in total behavior. Here the objectives are to help participants (1) make a commitment to a change process that helps them realize their potential; (2) abandon addictive "stinkin' thinkin"' and replace it with rational thinking processes; (3) take effective control of their lives by defining responsible behavior and holding themselves accountable for all their behavior; and (4) recognize recovery as a process •vith specific tasks as well as sticking points that can contribute to relapses into AOD use.
The Second TaskThe task is now to develop an agenda that will support a program of recovery. The objectives are to (1) provide training that allows the inmate to weave his or her own safety net and to network with community resources, (2) provide a network with community correction agencies in order to facilitate the inmate's accountability for recovery and changes in behavior, and (3) help the inmate understand that he or she alone is responsible for recovery and for the active role he or she must play in an aftercare program.
The Final TaskTherefore, during the treatment phase, the participant develops an agenda establishing goals in major life areas. A copy is forwarded to release authorities, for whom it is a powerful tool in measuring the inmate's progress. Project staff are currently developing a less extensive program for use at the awareness and education levels.
Definitive findings at this time are premature. However, the program's prognosis is favorable thus far based on feedback from field personnel and select case reviews.
Recently, project staff presented the networking and agenda concepts to a group of release authorities. Parole agents' caseloads are notoriously high. As a result, time often does not allow for development of individualized goals and a specific agenda to carry them out. Therefore, parole agents are supportive of any effort that aids them in holding an inmate accountable. Private sector agencies working with released felons have also applauded the agenda concept. They see development of an agenda and the accompanying network as enhancing the ability of offenders to get out of prison.
Individual stories, while isolated and unique, often carry more meaning than any accolade. One tells of a cocaine addict whose use led to sales and later to prison. Following treatment, his agenda led to appropriate aftercare and job placement through JTPA. While at the ISP he had become interested in computers. This interest grew into a college degree and a programming job at the trucking company with which JTPA had first placed him. This individual never tested positive for drug use and has been recommended for discharge from parole following several months of minimum supervision.
Upon release, 1-, 3-, 6-,12-,18-, and 24-month studies follow the progress of each treatment participant. Release authorities are asked to evaluate participants in such areas as use of AOD achieving primary and long-term goals, overall performance, and use of a sponsor. It is hoped this data base will identify critical elements of the agenda and network.
As a pilot project, it is too early to draw longitudinal conclusions on the effectiveness of the program. However, conclusions have been reached concerning the soundness of the project's conceptual framework and utility.
Conceptual FrameworkWhile developing this pilot project, we sought corroborating references to support these intuitive suppositions. Tammy Bell, M.S.W., CAC, Director of Relapse Prevention Services for the CENAPS Corporation, has identified six specific tasks the AOD user performs prior to entering treatment. Ms. Bell considers these tasks as the last stage of active AOD use and the first stage of recovery (Bell 1991).
From the beginning, project staff held a strong belief in the value of its study group experience. University Associates has developed a five-stage experiential learning cycle, which appears to be an effective tool in maximizing the ISP study group experience and helping inmates to become teachable (University Associates 1990).
Program UtilityFirst, regardless of the offender's length of sentence or the extent of his or her AOD problem, Project TEA offers some level of appropriate programming. The awareness and education levels of programming also provide valuable tools to correctional staff in evaluating the inmate's need and preparation for treatment.
Second, the Parole Board regularly requires inmates to participate in awareness and/or education prior to release consideration. The availability of the 7-week awareness and 13-week education programs allows the inmate to address AOD use while the consequences of confinement are evident.
Finally, Project TEA plays an important role in holding inmates accountable by networking institutions to community corrections and resources.
Awareness and education are proving to be valuable tools in preparing inmates for AOD treatment at the ISP. It is also a valuable learning eXperience for inmateS whose use of AOD has not crossed the line of abuse/ dependence. It would, therefore, seem prudent at this juncture to expand and actualize this concept. To accomplish this, the following recommendations are made.
First, staff believes the compilation of a workbook for awareness and education would significantly add to this learning experience. Such a workbook would clarify and expand upon concepts presented during the program and serve as a valuable tool in evaluating participation. In addition, the workbook would function as a continuing source of information throughout the program and on into recovery.
Second, two full-time coordinators should replace four part-time staff. This would ensure program consistency and allow for individual counseling at the awareness and education levels. At the same time, it would free the current full-time staff to focus their energies on treatment programming.
Lastly, networking between the ISP, community connections, and community treatment centers should be strengthened and expanded. Effective counseling demands that participants be held accountable for their behaviors and goals established during programming. To capitalize on their treatment programming and ISP experiences, open communication must exist between project staff and the free community.
Implementation of the above recommendations would allow staff to evaluate more accurately the effectiveness of Project TEA. A longitudinal study would follow participants at all levels and document both progression in the disease process and strides made in recovery.
Bell, T.L. Pretreatment: Getting ready for recovery. Addiction & Recovery 11(2):39-42, March/April 1991.
University Associates, Inc. The Experiential Learning Cycle. San Diego, CA: University Associates, Inc., 1990.
U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Drugs and Crime Facts. Rockville, MD, 1991.
Valle, S.K. Accountability training for addicted inmates. The Counselor 9(2):20-23, March/April 1991.
Zawistowski, T . A . Criminal addiction?/Illegal disease? The Counselor 9(2):8-11, March/April 1991.
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