Treatment compliance in the trajectory of treatment progress among ...

Journal of Substance Abuse Treatment 20 (2001) 153 ± 162

Regular article

Treatment compliance in the trajectory of treatment progress among offenders Hung-En Sung, Ph.D.a, Steven Belenko, Ph.D.b,*, Li Feng, M.A.a a

Kings County District Attorney's Office, 350 Jay Street, Brooklyn, NY 11201, USA The National Center on Addiction and Substance Abuse at Columbia University, 633 Third Avenue, New York, NY 10017-6706, USA

b

Received 1 November 1999; received in revised form 7 October 2000; accepted 9 October 2000

Abstract Research on drug treatment process has been limited, with most studies centering on individual and program factors associated with successful treatment completion. Recent literature has begun highlighting the salience of treatment engagement in reducing drug dependence among criminal offenders. This study descriptively analyzes incidents of treatment noncompliance identified in monthly progress reports for 150 criminal justice-mandated clients in residential treatment. We identify seven problem types and seven dimensions of noncompliance in the trajectory of treatment engagement. The latter are prevalence, frequency, types, specialization, temporal distribution, paths, and correlates. It is found that incidents of rule violations are common among criminal justice participants of residential treatment. Although for most clients these troubles do not appear to evolve into serious obstacles to recovery, a few clients with a high frequency of noncompliant behavior never engage in treatment. Clinical implications for improving treatment engagement and retention are discussed. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Treatment retention; Residential treatment; Treatment engagement; Noncompliant behavior; Criminal justice clients

1. Introduction A substantial body of research exists on the background characteristics of residential treatment participants (e.g., Anglin, Hser, & Grella, 1997; Hubbard, Marsden, Rachal, & Cavanaugh, 1989). There have also been important findings on the posttreatment improvements in social skills, criminal involvement, and drug use patterns among treatment participants under criminal justice supervision (e.g., Simpson, 1979; Simpson, Joe, & Rowan-Szal, 1997). Despite this literature, it has been noted recently that in addition to traditional comparison of pretreatment characteristics or posttreatment outcomes between groups, the mechanisms and conditions which underlie the treatment process for criminal justice clients are also worthy of further investigation (Broome, Knight, Hiller, & Simpson, 1996). Indeed, very little is known about the types and patterns of problems evinced by residential treatment clients during the

* Corresponding author. Tel.: +1-212-841-5200; fax: +1-212-9568020. E-mail address: [email protected] (S. Belenko).

treatment process. The high prevalence of substance abuse and addiction among offenders (Belenko & Peugh, 1998; National Institute of Justice, 2000), and the growing attention being paid to treatment-based interventions for offenders (Belenko, 2000; Inciardi, McBride, & Rivers, 1996) render it especially important to understand the dynamics of offender engagement in and compliance with treatment. Commonly studied dimensions of treatment process include motivation and readiness for treatment (De Leon, Melnick, & Kressel, 1997), emotional well-being and constructive therapeutic relationships (Bell, Richard, & Dayton, 1996), trust (Bell, 1994), psychological safety and staff competence (Wexler & Williams, 1986), and clinical strategies and elements conducive to change (Nielsen & Scarpitti, 1997). No attention, however, has been paid to the specific patterns of negative behaviors, and the clinical responses to noncompliant behavior in residential drug treatment programs. Yet relapse and maladaptive behaviors are common among criminal justice-mandated clients (Anglin & Hser, 1990). A better understanding of treatment noncompliance that often prevents resistant clients from completing treatment can help identify and engage these individuals before they drop out of or are expelled from

0740-5472/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 0 ) 0 0 1 6 0 - 4

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H.E. Sung et al. / Journal of Substance Abuse Treatment 20 (2001) 153±162

treatment. In this paper, we examine impediments to treatment compliance for criminal justice clients in residential drug treatment and attempt to elucidate those problems or incidents that can potentially deflect such clients from successful engagement. Treatment engagement refers to the level of treatment compliance of the client and is usually reflected through attendance, adherence to program rules, and active participation in the rehabilitation process. It is especially central to successful long-term residential treatment, which seeks to maximize clients' exposure to therapeutic interventions in highly structured environments. Although earlier studies underscored the relation between retention (time in treatment) and positive posttreatment outcomes (e.g., Simpson, 1979; McGlothlin & Anglin, 1979), more recent findings suggest that what is critical about treatment is not simply retention time, but ``rather it is the activities and the relationships that occupy the time of the drug abuser while in treatment that are important'' (Bell et al., 1996). Bell et al. (1996) found that difficulty in developing positive therapeutic relationships and an interference of anxiety and depression on treatment were considered signs of failures to engage in treatment, which in turn lowered retention rates. The role of treatment process on compliance, retention, and posttreatment outcomes, especially for criminal justicebased treatment, has been noted in recent research by Dwayne Simpson and his colleagues. In their general model of the therapeutic process, they have found that sequential therapeutic elements that are linked together over time have an impact on treatment retention and positive outcomes (Simpson, 1979; Simpson et al., 1997; Simpson, Joe, Rowan-Szal, & Greener, 1997). These elements include behavioral compliance with program requirements, relations with counselors, social and psychological functioning, and participation in program activities (Broome, Simpson, & Joe, 1999; Czuchry, Dansereau, Sia, & Simpson, 1998; Joe, Simpson, & Broome, 1999; Joe, Simpson, Greener, & Rowan-Szal, 1999). With a better understanding of the problems and the course of treatment noncompliance that often prevent resistant clients from succeeding in treatment, carefully designed strategies of intervention during critical points in the treatment process can help identify and engage these individuals before they drop out of or are expelled from treatment. This paper examines patterns of noncompliant behavior by criminal justice participants of residential drug treatment and attempts to elucidate those problems or incidents that can potentially deflect such clients from successful treatment engagement and completion. 2. Research questions The present study provides a descriptive analysis of treatment noncompliance among felony drug offenders

diverted from prison to long-term residential treatment. Seven basic dimensions were examined: (A) Background characteristics: What were the basic demographic, drug use, and criminal characteristics of clients who engaged in problem behaviors? Were noncompliant clients different from compliant clients in terms of these background characteristics? (B) Prevalence: How many of the participants engaged in problem incidents during treatment and how many refrained from noncompliant behaviors? (C) Frequency: The rate of infractions per participant was computed to assess whether there were any important differences between high-rate noncompliant clients and lowrate noncompliant clients, as well as between treatment failures and completers. (D) Types: The seven most serious and often observed types of problem conduct were studied. We also examined whether different types of treatment noncompliance received different kinds of clinical sanctions. (E) Specialization: Noncompliant clients might specialize in only one kind of problem behavior or diversify into a variety of problem behaviors. A classification of noncompliant clients by number of problem types elucidated the distinction between noncompliant clients who consistently repeated the same infraction throughout the treatment process and those who engaged in several types of noncompliance. (F) Temporal distribution: We examined the prevalence of problem incidents by month in the program. If treatment works as an intervention strategy, one would expect the distribution of problem incidents to be concentrated in the early stages prior to successful engagement in treatment. Furthermore, in accordance with the same argument, the onset of the first problem incident is expected have occurred in the initial stages of treatment. (G) Paths to treatment failure: A succession of problem incidents often led to expulsion from treatment. Although a few run-ins and infractions could be normally expected from new residents, the succession of problems may reveal an underlying unreadiness for treatment. We thus describe the course of problem incidents among treatment failures, both in terms of the length of time to treatment failure after the first problem incident and the number of incidents that were reported prior to the failure. 3. Methods and data This is a retrospective study that combines original data collected for an ongoing program evaluation with secondary administrative records. Beginning in May 1995, 150 consecutive admissions to the Drug Treatment Alternative-toPrison program (DTAP) operated by the Kings County District Attorney's Office (KCDA) were recruited from five different therapeutic community treatment programs (TCs) to participate in the larger research project (Belenko, Sufian,


Young, & Dynia, 1995). However, 87% of the participants were enrolled in three of the TCs. All protocols and procedures were approved and monitored by the Institutional Review Boards of the participating institutions. DTAP offers repeat felony drug offenders facing mandatory prison sentences an opportunity to participate in long-term residential treatment for 16 to 24 months as an alternative to prison. Eligible offenders are those charged with drug sale, have at least one prior nonviolent felony conviction, and have an underlying drug problem. DTAP relies on the TC as its treatment modality of choice and refers participants to one of several cooperating TC programs on a rotating basis. The original criminal charges are dismissed upon successful completion of the treatment program. Participants who drop out or are expelled from the treatment program are prosecuted on the original charges; nearly all are convicted and sentenced to prison (Hynes, 1998). The prosecutor's office monitors the treatment progress of DTAP participants through monthly progress reports. Participating treatment providers are contractually obligated to provide a monthly report on the performance, movement, and psychological and medical status of each client. The decision to report infractions to the prosecutor's office is based on established criteria. Some behaviors (e.g., drug use, physical violence, sexual acting-out, criminal activity, cover-up of criminal activity, and noncooperation) are explicitly stipulated as sufficient, although not necessary, reasons for expulsion. A written statement is required, and included in the monthly report, when a client breaks a rule, regardless of whether the infraction leads to termination or not. If the reports indicate a continuing problem or a serious infraction, the DTAP liaison arranges for the defendant to be admonished by the judge in an effort to increase the degree of pressure for compliance, while avoiding discharge by the treatment program. Terminal incidents for which participants were discharged from or voluntarily left treatment are reported in separate discharge letters. For the purpose of present study, the discharge letter was coded as the last progress report received for those who failed treatment. The information contained in the progress reports and the discharge letters was cross-checked to avoid double-counting problem incidents. The 150 research subjects received services at 17 different sites from the five treatment providers, and there was no centralized clinical database against which we could assess the cross-site reliability of the progress reports. Therefore, the data analyzed and reported here only relate to infractions that were detected and recorded by the treatment staff, and reported to the prosecutor's office. As such, any infractions or problem behaviors that were undetected by TC staff, or were detected but not written up in monthly reports to the prosecutor, would be excluded from the analyses. However, the number of undetected or unreported incidents is likely to be small. First, DTAP participants are serious offenders facing mandatory prison sentences if they fail treatment.

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Accordingly, the prosecutor's office requires both close surveillance by the TC and timely reporting of problem incidents. Second, the types of infractions and behaviors included in the present study are more likely to have been detected and recorded than other behaviors because they reflect either behaviors that occur in front of staff or that are specifically monitored by the provider. Third, undetected negative behaviors, by definition, are unlikely to influence treatment retention or performance in and of themselves because staff are not aware of the incidents. To the extent that these incidents lead to or are associated with other detected noncompliant behaviors, then client noncompliance would become known through other incidents. Nonetheless, the possibility that undetected or unreported infractions occurred among our sample must be acknowledged. A total of 1,939 progress reports were received from June 1995 to January 1999 for the 150 subjects. As of January 1999 all had successfully graduated from the program, failed treatment, or completed at least 24 months in treatment; average time in treatment was 17 months. Thus, progress reports were received and coded for 76% of all the treatment months for the 150 research subjects. With the exception of the first month of treatment, for which reports were available for only 65% of the participants, reports were received for 81% ± 96% of the participants in treatment in each of the following months. 3.1. Definitions of treatment problem types We identified seven categories of infractions that most often came to the attention of the clinical staff because of their negative influence on the treatment process. Problems are defined as the most common types of undesirable conduct or incident that predominate in the monthly progress reports. These problem behaviors were: (1) psychological withdrawal, (2) conflicts or fights with peers, (3) incidents of disobedience or insubordination toward staff members, (4) sexual acting-out, (5) theft, (6) drug relapse, and (7) leaving treatment without permission. The expulsion protocol negotiated by the prosecutor's office and the treatment providers explicitly stated that mandated clients could be terminated from the DTAP program for any of the seven rule violations listed above, although only ``splitting'' from the treatment facility actually resulted in automatic termination of treatment. The lack of participation is generically termed psychological withdrawal by the treatment staff. Peer encounters are mandatory for TC residents and critical to the mutual selfhelp process in that confrontational exchanges are encouraged to heighten images, attitudes, and conduct that need to be modified. Because of hostility, insecurity, or indifference, many residents do not talk, listen to others, or pay attention to what is going on during group sessions. Physical fights are not rare in TC environments where anxiety and frustration are maintained by the rigidly structured setting; on the contrary, they may constitute a

156


routine test to the supervisory establishment. Unfortunately, deficits in nonviolent conflict resolution skills and anger management capacities are common among criminal justice clients (Valliant, Ennis, & Raven-Brooks, 1995; Watt & Howells, 1999). The combination of the environmental inducements with individual behaviors adds some volatile ingredients to the life in therapeutic communities. Assaults against peer residents are highly disruptive because of their potential to ignite lasting feuds that can create alliances or counter-alliances. Acts of disobedience or attitudes toward staff refer to instances in which institutional rules and regulations are knowingly violated or instructions from clinical personnel are openly ignored or denied. Since one of the goals of residential treatment is to regenerate structure in the lives of treatment participants, respect for the rules is not only a means to change dysfunctional beliefs and conduct, but also an end in itself. Because of this, the management styles tend to be undemocratic, and daily routines highly regimented. Actions that challenge the purposeful authoritarianism and legalism are seen as symptoms of the same behavioral patterns that contributed to the problem of drug abuse in the first place. Many counselors allude to the prohibition of engaging in sexual activities with other residents while in treatment as one of the cardinal rules of the TC environment. The development of inappropriate physical intimacies among treatment participants is believed to be detrimental to the maintenance of therapeutic group processes founded on inclusiveness and openness; moreover, sentimental entanglement can easily displace residents' focus from recovery to matters of relationships. Sexual acting-out and theft pose particular threats in the context of treating TC residents: Sex and proceeds from theft can be used as exchange for drugs. Many drug abusers have learned from their street experiences how to maintain their drug habits through the trading of sexual favors and stolen goods (Inciardi, Lockwood, & Pottieger, 1993; Maher, 1997). Therefore, the prohibition of on-site sexual relationships and aggressive policing against theft indirectly serve to prevent the circulation of illicit drugs in the facilities. However, these two specific offenses are somewhat more difficult to detect than other problem behaviors, and their actual occurrence may be more frequent than identified in the progress reports. Periodic or irregular urine tests are conducted on TC residents to detect drug use relapses. The imposition of this regime of control is designed to deter treatment participants from using drugs during treatment. The level of tolerance for failing to keep clean varies among treatment providers, and first relapses are often confronted and forgiven. The least tolerated infraction was leaving the premises of the facility without permission. For DTAP participants, unauthorized departure from treatment is seen not only as a clinical failure but also as a legal breach of their agreement with the state. In this context, all treatment absconders are considered fugitives from law. Therefore, when a participant

absconds from treatment, an enforcement team from the prosecutor's office is notified immediately and mobilized to apprehend and to return absconders to court. Given that no participants ever presented two major problems in a single month, a categorical variable was created for each of the 24 months to track the reporting of problem incidents. There were a few exceptions where multiple problem incidents were detailed in discharge letters; the violation of several rules within a very short period of time might have prompted the expulsion of these participants. Two additional categorical variables were computed to capture these instances of multiple problems recorded in the discharge letters: Only residents who completed the full month of treatment were included in the calculation of monthly incident rates; and participants who either failed treatment or successfully completed the program were dropped from the months they were dismissed or graduated. Participants who never had any problem incidents reported were defined as compliant clients in our analyses, while those who had at least one infraction were termed noncompliant. Both treatment dropouts and expelled participants are referred to as treatment failures. 4. Results 4.1. Background characteristics Table 1 displays basic demographic and drug use characteristics of the sample. The subjects averaged 33 years of age. Clients without any problem incidents were significantly older (average: 35

Table 1 Background characteristics

Variables Mean age Gender (% male) Race/ethnicity Black Hispanic White Married High school diploma or GED Employed the year prior to admission (at least a week) Had juvenile arrest(s) Primary drug used Cocaine Crack Heroin Other * p < 0.05. ** p < 0.01.

Total sample (n = 150)

Compliant clients (n = 26)

Noncompliant clients (n = 124)

33 years 89%

35 years * 92%

32 years * 88%

37% 62% 1% 13% 27%

35% 61% 4% 12% 31%

37% 62% 1% 14% 26%

30%

37%

28%

27%

15% **

30% **

4% 30% 54% 12%

0% 28% 56% 16%

4% 31% 53% 12%


years old) than those with problems (32 years old). Women accounted for just over one tenth of the total sample. Nearly all study participants were either African American or Hispanic. Only 13% were married. Overall, clients without problem reports did not differ significantly from rule violators in terms of gender, ethnicity, or marital status. The noncompliant clients had somewhat poorer educational and vocational histories than compliant clients, but the differences were not statistically significant. In terms of self-reported criminal history, noncompliant clients were significantly more likely to have been arrested as juveniles (30% vs. 15%). The drug of preference was heroin, used as the primary drug by 54% of the study sample; the subgroups did not differ by drug of choice. These findings suggest that younger clients with poor educational and employment records and early contacts with law enforcement agencies were at the highest risk of engaging in problem incidents among participants of residential treatment. These same attributes have been found in other studies to be associated with a higher probability of treatment dropout (Chou, Hser, & Anglin, 1998; Miller, 1995; Simpson et al., 1997). 4.2. Prevalence Problem behaviors or disciplinary incidents were fairly common in this sample. A total of 319 problem incidents were reported by supervision staff over the 42-month observation period. Only 26 (17%) of the 150 participants never had a complaint leveled against them for behavioral problems during their stay in treatment facilities. The remaining 124 (83%) individuals had at least one incident of nonadjustment recorded in their monthly reports. This observation seems to confirm that drug treatment (particularly residential treatment) is a long process composed of ``a series of alternating treatments, failures, additional treatments, [and] additional failures . . .'' (Tonry, 1990: 5).

of noncompliant behaviors may be more apparent in the differences between low-rate and high-rate problem clients, rather than between those with any problems and those who are problem-free. 4.4. Types Some kinds of problem conduct were reported more often than others and treated differently. This could reflect differences in the underlying prevalence or in the likelihood of detection and reporting. Reported incidents of noncompliance normally were included in official progress reports to the district attorney's office because of their seriousness or high visibility, and interpreted as symptoms of resistance to change that had to be addressed. Rule violators were often denied advancement toward greater privileges or more responsible positions within the TC. The gravest infractions, such as absconding from the facility, almost always resulted in termination of treatment. Table 2 displays the distribution of noncompliant conduct by category as well as the frequency of treatment participants who infringed on the rules. The most common type of noncompliance was disobedience: Incidents grouped under this category represented 36% (115) of all reported problem behaviors. Adherence to directions given by treatment staff and respect for agents of authority seemed to be tough lessons with which residents grappled. Fifty percent (75) of the residents had, at some points of their treatment stay, engaged in actions of defiance challenging the staff or their instructions. These incidents were usually tolerated by the clinical personnel (only 5% of the clients displaying defiant behaviors were expelled as consequence) and often considered as being caused by internal struggles of the patient rather than

Table 2 Distribution of incidents and clients by noncompliance type Incidentsa

Clientsb

Clients terminatedc

Noncompliance type

n

%

n

%

n

Psychological withdrawal Disobedience/attitudes towards staff Conflicts or fights with peers Sexual acting-out Theft Drug use relapse Unauthorized departure Never had any problem reported Total

78 115

24% 36%

43 75

29% 50%

1 4

2% 5%

16

5%

13

9%

2

15%

21 4 33 52 ±

7% 1% 10% 16% ±

17 4 24 49 26

11% 3% 16% 33% 17%

2 1 8 45 ±

12% 25% 33% 92% ±

319

99%

±

±

±

±

4.3. Frequency A small group of high-rate noncompliant clients was responsible for a disproportionate number of infractions, while most clients only occasionally violated program rules and regulations. Thirty-two percent (48) of the sample accounted for 64% (204) of all the incidents reported in the progress reports. Each of the high-rate problem clients exhibited between 3 and 9 conduct problems serious enough to warrant official attention, while the rest of the sample only averaged one incident. For most residents, incidents of rule-breaking occurred but did not normally develop into chronic problems that undermined the treatment process. However, treatment failures did have more frequent problem reports than treatment completers, averaging 2.4 incidents each, compared with 1.9 incidents for completers ( p < 0.05). The clinical significance

157

a

%

The percentages do not add up to 100% because of rounding. b The sum of the percentages exceeds 100% because many noncompliant clients engaged in more than one type of noncompliance. c Four cases of treatment termination involved multiple terminal problem incidents.

158


triggered by external conflicts, as illustrated by the following case: There was a incident (sic) in the month of July in which A acted out his frustration by becoming verbally abusive to staff. A understands that this is inappropriate behavior and has demonstrated a willingness to working (sic) with staff to find new coping mechanisms (from A's tenth monthly report).

Psychological withdrawal was the second most widespread problem, comprising 24% (78) of the incidents and involving 29% (43) of the sample clients. Counselors regularly expressed their concern over residents who seemed only to be going through the motions of counseling sessions without substantive involvement in the therapeutic dynamics. Despite its frequent occurrence, psychological withdrawal was the most tolerated type of noncompliance: Only one participant was expelled for ``not responding to treatment.'' The following excerpt from the progress reports of a client with repeated accounts of psychological withdrawal illustrate how this problem is perceived by treatment counselors. B has the tendency to be compliant with authority figures. However, his peer interaction and participation in the environment is minimal. B needs to take more of an initiative in those areas stated above (from B's fifth monthly report). B needs a lot of work on being assertive and sharing himself with others. He tends to lay back unless engaged and pushed to do things (from B's twelfth monthly report).

Relapse to drug use was infrequent in this sample. The main reason is that prohibitions against the use of drugs and alcohol were the most conspicuous rules in effect in the TCs. In principle, any infringement of these strongly enforced regulations typically resulted in immediate expulsion. Many of the 24 (16%) residents who were caught using drugs or tested positive in urine tests were forgiven and given a second chance. Yet relapse to drug use was still the most important reason of treatment expulsion among this group: 33% of the relapsed clients were immediately terminated. Tightened monitoring and enhanced counseling sessions invariably followed positive urinalyses for those who were allowed to continue treatment. C was out recently on a home visit, and was given a random urine test that came back positive for opiates. We are currently awaiting to retest the results (from C's sixth monthly report). On August 10, 1997, D was given a urine test and tested positive for morphine. At that point D lost her job and was placed on a learning experience. She has begun to reevaluate her reasons for coming into treatment. D receives one-on-one counseling and attends seminars, rap sessions, female workshops, and group therapy three times a week (from D's fourth monthly report).

Although only defendants without a history of violence were admitted into DTAP, a few violent incidents occurred

during treatment. Sixteen incidents of violent altercations or physical clashes were reported, representing 5% of all reported incidents. Thirteen (9%) of the 150 clients engaged in a violent incident and only two of them were terminated as result. These incidents often involved disputes over control of territory or property and were all thoroughly and quickly investigated by supervisory staff. On February 13, 1997, client was involved in an incident in which he broke another resident's boundaries by pushing him with his shoulder. There was a disagreement over the use of a washing machine. He admits to breaking a cardinal rule and takes ownership for his actions. E was evaluated and will be given a revised treatment plan to follow in order to address this attitude and behavior (from E's sixteenth monthly report). On Thursday, March 22, at approximately 11:00 p.m., F went into another resident's room and proceeded to confront this resident on stealing his ring. The confrontation resulted in a serious physical altercation where one resident was sent to the emergency room for minor head injury (from F's seventh monthly report).

Twenty-one incidents of sexual acting-out were reported, accounting for 7% of the problem incidents. Seventeen people, or 11% of all those with problem incidents, had engaged in physical intimacies of varying degree. Given the covert nature of sexual activities, only a few incidents labeled ``sexual acting-out'' actually involved sexual intercourse caught in vivo, which might explain why only two of the 17 violators were terminated. Typically, counselors made inferences of sexual relationships from acts of open flirtation or sexual attraction and confronted residents involved on basis of their suspicions. The slightest expressions of sexual intimacy were flagged in progress reports to remind monitoring criminal justice agents of the distracting effects of developing sexual relationships in the TC setting. G has been dealt with by the staff this month for kissing a female resident. G responded well to the learning experience, but the incident showed again G lacks motivation and interest in his future which is a big concern (from G's fourteenth monthly report). . . . H has broken one of our most important rules. After being missing for approximately 1-1/2 hours, he was found behind our gym with a female resident. H is now on a learning experience for his actions and has been given several awarenesses to separate his actions from this female, which he has refused to do. His behavior is being carefully monitored at this point (from H's third monthly report).

Leaving the treatment facility without permission usually led to automatic termination of treatment. Despite being informed in advance of the serious consequences of dropping out of treatment, the treatment progress reports indicated that 49 participants left without permission and absconded. This number of splitters comprised 33% of all


159

Nevertheless, some consistent and interesting patterns emerged among multiple rule breakers. The occurrence of some types of violations seemed to predict or to inhibit the occurrence of other incidents. Two pairs of problem behaviors were strongly correlated. First, disobedience was negatively associated with splitting treatment. Ninety-three percent of the multiple rule violators who never displayed attitudes toward staff had become absconders, while only 30% of those who exhibited insubordinate behavior absconded (not shown in the table). Second, experiences of drug relapse were related to decreased likelihood of psychological withdrawal from participation in counseling sessions and other treatment activities. Nearly two thirds (64%) of the multiple rule breakers who had experienced drug relapses had never demonstrated withdrawal during counseling sessions, in sharp contrast to the 11% of those multiple rule breakers who had drug relapses and reports of psychological withdrawal. Both findings of association were statistically significant at the 0.0001 level.

rule breakers and 16% of all problem incidents reported. Forty-five (92%) of them were terminated and brought back to court for prosecution on the original charges, and the remaining four were readmitted to treatment after pleading guilty to a felony charge. 4.5. Specialization For clients who had multiple reported incidents, we analyzed the extent to which they specialized in certain types of problem conduct. Some may show high versatility by breaking more than one type of rule, while others may be more specialized in the kind of problems they cause. Data showed that although 53 (43%) single-rule violators were found, 57% of all noncompliant clients had violated more than one type of regulation. Most of the 53 rule breakers who reported only one type of incident of noncompliance were involved in disobedience or absconding (not shown in the table). Over half of the noncompliant clients had failed to comply with two or more different kinds of regulations. These findings suggest a lack of ``specialization'' among rule breakers. In other words, treatment clients who committed one type of infraction had a tendency also to diversify their noncompliance. Rather than the development of a specific behavioral dysfunction, noncompliance in the trajectory of treatment progress might be seen as a nonspecific, general inability to accommodate to a highly structured therapeutic environment.

4.6. Temporal distribution Noncompliant behaviors do not appear to evolve evenly or randomly over the treatment process. From a clinical perspective, the frequency and severity of trouble incidents should decline as treatment starts to exercise positive effects on participants' personality, value system, and pro-social skills. The analysis corroborated this expectation.

Fig. 1.

160


The calculation of monthly prevalence of noncompliance and the annual average of monthly prevalence rates only included participants who were actually at risk of showing problem conduct for the specific month; participants who successfully completed treatment were excluded from the month of their completion. Not surprisingly, the prevalence rate was highest in the first month of treatment, when 24% of all participants had some type of problems reported by their TC (Fig. 1). In parallel, the three lowest monthly prevalence rates were observed during the last six months of the 24-month followup period, with only 5.7%, 4.7%, and 6.2% of participants breaking rules in the 18th, 21st, and 23rd months, respectively. Looking at the annual averages of monthly prevalence rates, a clearer picture emerges. The first 12 months averaged a prevalence rate of 17.5%, as compared to the 10.3% for the second year. As therapeutic efforts started to take effect and unready participants were eliminated through the self-selection process of dropping out, behaviors and attitudes regarded as incompatible with drug-free, productive lifestyles sharply decreased. The other question of interest was related to the onset of participants' problem behaviors. It can be hypothesized that if treatment is effective, the likelihood of initiating noncompliant behaviors will decrease over time. Our data confirmed this. Among participants who had produced at least one problem incident, only 14% of them experienced their first incident during the second year of treatment, and no client had their first problem incident after the 20th month in treatment. Nearly two thirds (63.7%) of those who engaged in problem activities initiated their noncompliant behavior in the first six months. 4.7. Paths to treatment failure The problem incident patterns of the 59 treatment failures were examined. The paths to treatment termination were measured in terms of both the length of time lapsed and the number of incidents that occurred between the report of the first incident and the terminal incident that resulted in the exclusion from treatment (Table 3). This analysis helped answer the question of how long and how many problems had occurred before a participant left or was terminated from treatment. The 59 treatment failures averaged two incidents each and five months between the report of the first incident and treatment termination. About one third (32%) were expelled or left voluntarily in the month in which the first incident occurred. In terms of the intensity of problem behavior, 78% of the treatment failures reached their treatment termination before they generated a fourth problem incident (Table 3). Only 22% were allowed to have four or more incidents on their record before being terminated. In general, then, criminal justice clients in the highly structured environment of residential treatment are not allowed to develop lengthy patterns of

Table 3 Paths to treatment failure: length of treatment stays and number of problem incidents before termination (n = 59) Treatment failures Characteristics Length of treatment stays before termination Failed treatment with first problem incident Failed treatment 1 ± 6 months after first incident Failed treatment 7 ± 12 months after first incident Failed treatment 13 ± 23 months after first incident Total Mean Median Number of problem incidents reported Failed treatment with first problem incident Failed treatment after 2 ± 3 incidents Failed treatment after 4 ± 6 incidents Failed treatment after 7 ± 9 incidents Total Mean Median

n

%

19

32%

22

37%

11

19%

7

12%

59 5 months 2 months 19 27 12 1 59 2 incidents 2 incidents

100%

32% 46% 20% 2% 100%

noncompliance before being terminated. Most treatment failures (69%) were terminated within six months of their first problem incident, while fewer than one third (31%) of the treatment failures survived for more than six months after the first incident. 5. Discussion This study described and analyzed seven dimensions of problem incidents in the trajectory of treatment engagement. For many clients, problems can be described as common, nonspecific, and sporadic infractions that preceded effective treatment engagement. But, for a small group of participants, persistent noncompliant behaviors led to treatment failure. There was no difference between occasional and persistent noncompliance in terms of the onset of the first problem incident because most clients engaged in their first problem incident during the early stages of treatment. But there were some background characteristics that distinguish compliant clients from noncompliant clients. Factors associated with noncompliant clients in this study (young age, poor education and employment background, and early involvement with criminal justice system) are similar to those characteristics found to correlate with abuse of hard drugs, shorter treatment retention, and negative posttreatment outcomes (Anglin and Hser, 1990). The convergence of findings suggests that the same causal dynamics that first lead a person into drugs and crime may also hamper his or her treatment engagement and increase the likelihood of treatment failure.


Problem incidents pose a particular challenge for residential treatment providers. Effective drug treatment has been viewed as a combination of three key ingredients: a long period of intervention, a high level of structure, and flexibility (Anglin and Hser, 1990; National Institute on Drug Abuse, 1999). Treating criminally involved drug abusers, because of concerns over public safety, further complicates the dilemma of maintaining a significant level of discipline and control in the treatment setting without sacrificing flexibility and retention. Based on findings from this descriptive study, several recommendations can be suggested regarding the design and implementation of effective treatment strategies. The observation that treatment clients usually experience difficulties in following program rules and regulations suggests the importance of making these rules and regulations more flexible, especially during the early stages, to lower the initial dropout rates and adjust to the typical trajectory of treatment progress. There appears to be a real potential for ameliorating the impact of initial manifestations of noncompliance, given that the majority of the noncompliant clients did eventually engage in and complete treatment. Adjustment and behavioral problems are likely to occur, so that the creation of predictable, but not final, penalties for noncompliant behavior might be considered. The model of structured and escalating sanctions for program noncompliance used in treatment drug courts offers one potential structure (Belenko, 1998), and may account for the high retention rates found in these programs (Marlowe & Kirby, 1999; Office of Justice Programs, 1998). High-rate noncompliant clients are very disruptive in the therapeutic setting and may consume a disproportionate share of resources. Therefore, their continuity of maladaptive behavior before and during treatment suggests the importance of early identification and specific intervention. Because problem conduct often negatively affects peer residents, ignoring the special needs of high-rate noncompliant clients may sabotage their progress toward recovery. Treatment should address underlying personality or social dysfunction of these core noncompliant clients, not just their drug use. Intensive behavioral therapies that enhance interpersonal relationships and the individual's ability to function in the family and community may be very useful. If an essential aspect of treatment is to gradually eliminate noncompliance, then these clients may need to remain in treatment for longer periods of time to successfully engage in treatment. For this group of legally mandated clients, the attainment of instrumental goals such as attendance, adherence to program rules, and active participation in counseling sessions may be as critical as desisting from drug use. The behavioral dimension of failure to engage in treatment is a relatively neglected area in drug treatment research. The present study has made some initial exploration of this area and laid the groundwork for future investigation. Subsequent research should identify the specific determinants of

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particular noncompliant behaviors, their effects on posttreatment outcomes, and the relationships between in-treatment problems and other problem behaviors.

Acknowledgments This article was prepared with the support of Grant #1R01-DA09075 from the National Institute on Drug Abuse, U.S. Department of Health and Human Services to Steven Belenko, Ph.D., principal investigator. The authors thank the treatment providers, Aurora Concept, Daytop Village, Phoenix House, and Veritas, for their cooperation throughout the data collection process, and the Kings County District Attorney's Office (KCDA) for permission to use its administrative records. The comments and suggestions by Dr. A. Thomas McLellan and two anonymous reviewers on an earlier draft of this article are gratefully acknowledged. Points of view or opinions expressed herein are those of the authors and do not represent the official positions or policies of the U.S. Department of Health and Human Services, the National Institute on Drug Abuse, the National Center on Addiction and Substance Abuse at Columbia University, or the Kings County District Attorney's Office.

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