Am J Crim Just (2016) 41:112–123 DOI 10.1007/s12103-015-9325-3
Validating Program Fidelity: Lessons from the Delaware County Second Chance Initiatives J. Mitchell Miller 1 & Holly Ventura Miller 1
Received: 17 December 2015 / Accepted: 17 December 2015 / Published online: 11 January 2016 # Southern Criminal Justice Association 2016
Abstract Reentry programming for offenders has increased considerably since the passage of the Second Chance Act in 2008. This study presents findings from the implementation and process phases of a multi-stage program evaluation of two Second Chance Act funded initiatives in Delaware County, Ohio. Two distinct programs, one for offenders diagnosed with co-occurring mental health and substance abuse disorders and another for substance dependent offenders with minor children, were examined using a mixed-methodological research design incorporating process and outcome phases. Process findings focus on determinations of program fidelity and adherence to evidence-based practices. Discussion centers on the role of process evaluation in assessments of intervention effectiveness and the importance of establishing program fidelity prior to outcome analysis. Keywords Process evaluation . Program fidelity . Reentry
Introduction Rehabilitative programming designed to assist offender transition back into the community is commonly known as reentry and typically oriented around individualized and holistic treatment (Travis, 2005; Visher, 2006). Individualized treatment addresses multiple offender needs and serves as a cornerstone of effective rehabilitation. Because offenders face a number of challenges, individualized treatment plans typically address multiple issues such as substance abuse, mental health, housing, employment, familial
* J. Mitchell Miller
[email protected] Holly Ventura Miller
[email protected]
1
Department of Criminology & Criminal Justice, University of North Florida, 1 UNF Drive, Jacksonville, FL 32224, USA
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strife, post release treatment continuation, and community correctional supervision compliance (Miller, 2014; Miller & Miller, 2010; Steadman & Veysey, 1997). Positive outcomes derived from reentry programming tend to be dependent upon both individual factors and program-specific characteristics such as the fit of chosen modalities, duration of program exposure, and context of treatment delivery (Brewster & Sharp, 2002; Howells & Day, 2006; Krienert & Fleisher, 2001; Roman, Wolff, Correa, & Buck, 2007; Walters, 1999; Welsh, McGrain, Salamatin, & Zajac, 2007; White, Saunders, Fisher, & Mellow, 2012). Prior research on reentry has often focused on the prison setting and relied on recidivism and survival rates as the primary (and often only) measure of program effectiveness. Consequently, very little is known about other positive outcomes such as in-program benefits or non-operationalized post-release outcomes (Mears, 2010; Miller, 2014). Exclusive focus on quantitative outcomes also fails to account for daily program realities and can obscure contextual factors important for understanding program effectiveness. While traditional experimental or quasi-experimental designs can specify program effects, rigorous process evaluation incorporates the influence of program realities and dynamics not readily measured. Unfortunately, few published evaluation studies have incorporated the use of process evaluation to empirically establish program fidelity (Miller & Miller, 2015; for exceptions, see Esbensen, Matsuda, Taylor, & Peterson, 2011; Esbensen, Peterson, Taylor, & Osgood, 2012; Melde, Esbensen, & Tusinski, 2006; Latessa, 2004; Lowenkamp, Latessa, & Hollsinger, 2006). Fidelity is the extent to which delivery of an intervention, modality, or treatment adheres to program design. Because programs operate in real-world settings, practical issues, politics, and unanticipated consequences can often spur innovation and adaptation in program delivery (Carroll, Patterson, Wood, Booth, Rick, & Balain, 2007; Rohrbach, Gunning, Ping, & Sussman, 2010). Consequently, researchers must consider if changes occur during program start-up or throughout the life of a program so that observed outcomes can be attributed to treatment delivered as intended, rather than some altered version. Establishing program fidelity in evaluation research is critical for several reasons. First, process evaluations can generate immediate feedback to practitioners for program improvement and document program accountability in terms of whether service providers are compliant with grant conditions and treatment delivery expectations. Process evaluation also enables collection of data directly from key program stakeholders including administrators, staff, and participants, as well as observation of program activities and content to ensure consistency with intervention design. Perhaps most importantly, program fidelity research can elucidate the Bblack box^ of evaluation through insight into how and why a program is or is not effective. This paper relates the process evaluation phase findings from the Delaware County (OH) Second Chance Initiatives which included the Delaware County Transition Program (DCT) for co-occurring offenders and the Delaware County Jail Substance Abuse Treatment Program (DCJSAT) for substance dependent offenders with minor children. Twelve site visits over two years were executed for data collection from program administrators, treatment staff, and incarcerated participants. These site visits entailed the observation of program activities and review of program content to confirm that training materials and delivery protocol were consistent with modality design. Qualitative data collection was guided by interview schedules and the Justice Program
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Fidelity Scale (JPFS) to ensure systematic topic coverage and attention to requisite fidelity concepts (Miller & Miller, 2015). After offering a brief review of the program fidelity literature, this study describes the two Second Chance programs and the evaluation strategy. Key findings relate implementation intensity and the quality of delivered services while informing further process applications in justice settings.
Background Program underperformance is typically considered a function of either theoretical or implementation failure (Bickman, 1987). Theoretical failure refers to the ineffectiveness of the treatment or intervention and assumes that the program operates as designed. Implementation failure, on the other hand, entails programming that is sufficiently divergent from modality design, treatment timeframe, or delivery protocol so that actual services are not consistent with the modality as originally conceived. Distinguishing between the two is critical, as implementation failure obscures determination of theoretical failure. If evaluation research neglects fidelity, observed outcomes may be a function of delivered programming but not necessarily attributable to the chosen modality. Rather, results may be attributable to some element of varied rather than the intended treatment strategy, or mere coincidence. Key fidelity concepts were introduced to criminology and criminal justice largely through the work of Esbensen and colleagues (2006, 2011, 2012). Program fidelity is comprised of both the structural components of an intervention (e.g., evidence based nature of the selected modality, counselor caseload, staff size, treatment provider credentials, and the frequency and timeframe of treatment sessions) and dynamic realities within the treatment environment. The latter are reflective of the nature and quality of interaction and rapport between treatment program stakeholders (i.e., program administrators, staff, and participants). A number of fidelity concepts have been introduced, redefined, and improved in recent years, resulting in general consensus that five domains are indicative of implementation intensity and modality compliance (Carroll et al., 2007; Esbensen et al., 2011; Rohrbach et al., 2010). Adherence refers to delivery compliance with treatment design during both implementation and over the life of a program. Adherence specifies whether screening tools and treatment services are evidenced based and formatted according to treatment expectations regarding dosage. Exposure is a temporally indicated construct and references frequency of counseling, other therapeutic services, number of sessions delivered, and session duration. Delivery quality is determined through treatment and support staff quality indicators such as professional credentials, attitude, and continued professional training. Participant engagement refers to the extent of demonstrated participant Bbuy-in^ to programming activities and treatment objectives indicated by attitude regarding participation and degree of involvement in treatment activities. Finally, program differentiation refers to whether the program is delivered consistently over its life-course in terms of maintaining approximate program size, individual counselor caseload, continuity of setting and treatment staff, and budget consistency indicative of equal resource allocation over time. Collectively, these concepts inform the development of specific process and fidelity focused research questions, such as: Does the program adhere to evidence based
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practices (EBP) that have documented success in addressing the targeted problem in the delivery setting?; Does the program deliver treatment in a manner consistent with prescribed program protocol?; and What effect does the program have on facility climate in terms of interaction among inmates and inmate-staff interaction? Address of these important research questions enables identification of treatment barriers, elevates confidence in observed outcomes, and contextualizes statistical findings (Miller, Tillyer, & Miller, 2012; Miller & Miller, 2015).
The Current Study: Program Overviews DCJSAT (Family-Based Treatment Program) The Delaware County Jail Substance Abuse Treatment (DCJSAT) program (see Miller, Miller, & Barnes, 2016) targeted serious drug-abusing offenders who met two criteria: 1) diagnostic criteria for substance dependence using the SOQIC, and 2) voluntary participation. The program utilizes the Community Reinforcement and Family Training Model (CRAFT), a treatment modality for substance abuse involving both operant conditioning and family-based therapy for behavioral modification (Meyers & Squires, 2001; Meyers, Villanueva, & Smith, 2005). Empirical evidence suggests that the CRAFT model produces outcomes more favorable than programs with only one treatment component (Meyers, Miller, Hill, & Tonigan, 1999; Szapocznik, Kurtines, Foote, Perez-Vidal, & Hervis, 1983, 1986). The CRAFT modality has been shown as particularly effective for alcohol and opiate-addicted populations (Abbott, Weller, Delaney, & Moore, 1999). The DCJSAT program targeted 34 moderate to high risk male substance dependent offenders housed in a unit dedicated to this initiative and physically separated from the general jail population. The program operated on a rolling admissions basis so as to operate at full capacity and a Reentry/Recovery Coordinator maintained a waiting list for services to further ensure optimal utilization. The program was delivered across three interrelated phases (medical stabilization, primary treatment, and aftercare maintenance) toward the goal of providing a seamless continuum of offender engagement beginning in the jail and continuing after release. DCT (Co-occurring Offender Program) The DCT program is a close iteration of a crimesolutions.gov rated Bpromising^ intervention originally developed in nearby Auglaize County, Ohio (ACT program) featuring an individualized treatment intervention approach. Mixed-methods evaluation found the ACT program successful in terms of public safety (recidivism and new crime reduction), correctional facility climate improvement (reduction in inmate-on-inmate and inmate-staff confrontations), and rehabilitative/offender lifestyle betterment (treatment participation, employment, and improved familial cohesion) objectives (Lynch & Furstenau, 2008; Miller & Miller, 2010; Miller, 2014). DCT program staff (1 reentry coordinator and 1 case manager) connected offenders with the specific services and counseling necessary to resist criminal behavioral relapse and disrupt offending trajectories. Staff received referrals to the program, met with
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offenders individually and in groups, conducted assessments, assisted offenders in developing individualized Reentry Accountability Plans, coordinated mental health, medical and drug treatment, and linked offenders to community resources following release. Recovery services, anger management, mental health and other identified services were provided by credentialed partner agencies. In short, reentry case management proactively engaged offenders and coordinated stakeholders to effect therapeutic collaborations comprising a continuum of reentry services toward the goals of enhancing the likelihood of offender success and safer communities.
Research Design Comprehensive program evaluation entails both determining if the treatment reduces recidivism and relapse as well as identifying the particular components of the modality responsible for observed outcomes. Given the possible barriers that an exclusively quantitative approach may present for understanding program functioning and holistic value, a mixed-methodological (i.e., qualitative and quantitative) approach offers the ability to contextualize quantitative findings through program stakeholder input and direct observation of program sessions and activities. The process assessment strategy was employed within mixed-methods evaluations of the programs. Guiding questions regarding program operation, delivery, and utility included: 1) Do the programs adhere to evidence based practices that have documented success in addressing substance abuse disorders within correctional settings? 2) Do the programs deliver treatment in a manner consistent with prescribed program protocols thereby demonstrating program fidelity? 3) What effect do the programs have on facility climate in terms of interaction among inmates and inmate-staff interaction? First, we focused on program content and its delivery to identify possible problems, barriers, or other issues relevant to program operation and success. This qualitative phase consisted of a dozen site site visits to each program which included in-depth interviews with facility administration and program staff, focus group interviews with a sample of treatment group participants, and observation of treatment services to demonstrate program integrity in terms of modality and grant conditions compliance. Fidelity was assessed and measured in five program domains per the JPFS (Miller & Miller, 2015) to ensure systematic assessment for meaningful comparison across program junctures (Appendix).
Implementation and Process Evaluation Findings Process evaluation findings were generally positive, but mixed (see Table 1). Both programs featured evidence-based practices, delivered confirmed treatment modalities (Moral Reconation Therapy and Community Reinforcement and Family Treatment), and maintained staff with professional credentials that received additional training
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Table 1 Delaware county Sheriff’s office 2nd chance act offender treatment programs: program fidelity assessment DCJSAT
DCT
Fidelity indicator Adherence
Low
Low
Exposure
High
High
Delivery quality
High
High
Participant responsiveness
High
High
certifications during the funding period. Specification of the daily routines of the treatment offenders (by gender) in each program enabled documentation of exposure and dosage, which met or exceeded contact and treatment hours through a combination of individualized and group treatment services. Program fidelity indicators such as exposure, dosage, and participant responsiveness were scored high for both programs, but adherence to program design was problematic and a function of chronic administrative turnover and a related turbulent climate characterizing the DCSO, generally, and the jail and its programming, specifically, throughout much of the grant period. Administrative ideological endorsement of programming has been identified as a vital aspect of successful rehabilitation within the criminal justice system and its absence is a confirmed barrier to successful substance abuse treatment in correctional contexts (Miller, Koons-Witt, & Ventura, 2004). Agency support for the grant initiatives clearly waxed and waned across the three administrations within the 2-year period. Change in the jail administrator position—the individual with direct supervision over programming—impacted working conditions for program staff, treatment provider access conditions, treatment inmate housing, and, especially, rapport between the treatment team and DCSO correctional staff. During the 2-year delivery period for each of the programs, DCSO was led by three sheriffs. Problems that emerged with the resignation of the first sheriff, which swelled during the tenure of the interim sheriff, were ultimately tempered and addressed by a third acting, and then elected, sheriff. Despite considerable change and a climate of administrative uncertainty during much of the grant period, the treatment staff maintained fairly consistent delivery through focused re-coordination and commitment to the treatment mission. While not optimal due to a lack of adherence to some evidence based practices, the programs were delivered with sufficient fidelity that observed outcomes can be attributed to treatment services. Under the supervision of the initial DCSO jail director, implementation transpired slowly but was thoroughly executed. Delays were attributable to an Barrested development^ of functioning by the DCSO administration as the onset of program start-up corresponded with controversy in the DCSO associated with the events that led to the resignation of the original partnering sheriff. During this time, few official decisions were made and delays in launching the programs were, in part, a function of minimal processing of grant-related contracts and invoices. Though the Sheriff had previously exhibited pointed interest in the programs, the turmoil in his office at
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implementation overshadowed treatment and other activities in the jail and the programs were rolled out without strong support from DCSO administration. There was little continuity regarding the programs across the three sheriffs. Grant planning, submission, award, personnel staffing, and implementation transpired under the supervision of the former Sheriff who resigned in April 2012. Treatment delivery, including midstream modifications to programming, occurred under the administration of an acting sheriff appointed that same month, and then the final Sheriff (first appointed by the Delaware County Republican Central Party in June 2012 and then elected the following January) who oversaw the conclusion of the programming period. The programs were also immediately supervised by three administrators over the 2year period: the partnering jail director, the Deputy Chief in an interim capacity, and a second jail director. The first jail director demonstrated pronounced perseverance pushing forward with the initiatives despite the absence of administrative support. Early evaluation site visits focused on implementation intensity and the inclusion and actualization of evidence based practices called for in the program designs. Initial assessment specified program overstaffing for the family-based initiative (each program was planned to have a coordinator and a case manager), but the difference in program size indicated that two full-time staff for the DCJSAT program was unnecessary and a misuse of resources. Whereas EBPs guided program implementation (e.g., the isolation of DCJSAT treatment participants from the general population), the resignation of the first Sheriff signaled agency change that was near categorically detrimental to programming. While there were several delays in finalizing staff hires and contracts with professional service providers, the programs were implemented with general intensity and considerable professionalism—a reality that faded almost immediately under the supervision of the anti-treatment attitude projected by the acting sheriff. DCSO correctional staff began to voice negative and dismissive attitudes about the former Director and programming, seemed to resent the presence of the treatment staff within the jail (perhaps because all but one member of the treatment team and administration had masters degrees compared with high school diplomas for most officers), and interpreted daily activities associated with programming (i.e., inmate movement for treatment and the logging in of visiting treatment providers) as unnecessary extra work. The acting sheriff worsened an already apparent divide within the agency between a dedicated minority supportive of offender programming, its goals, and mission and an entrenched majority that viewed programming as little more than leniency and the coddling of offenders (i.e., a clash of penal ideologies). Suddenly and independent from any larger facility agenda, the treatment team, though not sworn officers, were told they would be required to wear uniforms and treatment inmates that were, per program design, to be housed separately to constitute a therapeutic community approach and access the mutual support for recovery therein, mixed with general population inmates. Questions regarding the basis for changes were answered with a general response of Ba need for getting things back to how they should be^ and Bthere is a need for authority and order^ communicating that a conservative-punitive orientation to offender treatment was the new order of the day. Communication between the treatment team and DCSO became almost non-existent and inconsistent at best. Program neglect was also apparent through several grant adjustment notifications required for expanded timeframes associated with a start-
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stop approach to programming that ultimately led to needed no-cost extensions. Many of the correctional staff followed the acting sheriff’s lead of devaluing offender programming and the treatment team, culminating in very poor rapport to the point that treatment team members began to consider employment alternatives. The negative climate surrounding the Acting Sheriff extended to the evaluation team. Evaluators had been previously introduced to correctional officers at the DCSO jail’s check-in window to facilitate the assignment of visitor badges and effect familiarity with inmate movement and related evaluation activities. Under the acting sheriff, a more cumbersome and excessively formal sign-in and waiting procedure was implemented. Though opportunities to interact with the acting sheriff were limited, it is uncertain if he ever had definitional understanding of the programs, their missions, and prospects for community betterment. Accordingly, it is difficult to specify the basis of reaction formation detrimental to programming other than ideological inclination and, perhaps, fear of the unknown. Treatment staff morale was understandably very low when the next and current Sheriff assumed the position. The new Sheriff replaced the Jail Director with an Interim Director whose initial service period was extended throughout the duration of the funding period. In 2012, the former Director had been working on program sustainability plans as the positions had but a year of funding remaining. Fortunately, the new Sheriff chose to maintain programming and assigned oversight to the agency’s Chief Deputy during transition in the Jail Director role. Daily routines smoothed and the projection of support for the treatment programs by facility administrators quickly trickled to correctional staff. The treatment staff reported improvements in the working climate and the evaluation team experienced better access to the facility and more professional interaction that predated the bullish authoritarianism characteristic of previous leadership.
Conclusions & Implications Delivering effective reentry-oriented drug treatment is an efficient approach by which to reduce drug crime, maintain public safety, and help offenders rebuild their lives, reconnect with their families, find meaningful employment, and become productive members of society. Ensuring that reentry programs are evidence-based is a critical first step for establishing effective practices suitable for replication. While many studies have assessed program outcomes, few utilize process methods to first establish program integrity. This is an unfortunate oversight as process assessment offers several benefits to program evaluation design, including the generation of immediate feedback to practitioners for program improvement. Process evaluation also enables collection of data from those with the greatest knowledge of programming—key stakeholders such as administrators, staff, and participants. Finally, program fidelity research can shed light into the Bblack box^ of evaluation findings, providing insight into how and why a program is or is not effective. As noted previously, contextual realities have the ability to alter or otherwise interrupt intended program delivery. These daily realities may constitute implementation failure which may be incorrectly interpreted as theoretical, or program, failure by the majority of researchers who typically forgo fidelity steps. By incorporating rigorous
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process evaluation activities such as interviews, observation, and document analysis, researchers can confirm the presence or lack of program fidelity shedding light on the how and why of observed outcomes. Process evaluation findings from the Delaware County Second Chance Initiatives were generally positive although certain aspects of program fidelity were found lacking. Both the DCT and DCJSAT featured evidence-based practices and treatment modalities supported by prior empirical research (Moral Reconation Therapy and Community Reinforcement and Family Treatment, respectively). Delivery quality was generally high as reentry staff were properly trained and credentialed. Similarly, participant engagement was also scored high based on interviews with offenders and observation of treatment activities. That such a high level of mutual engagement was maintained with approximate intensity over the bulk of programming under difficult and changing circumstances is a testament to the professionalism and dedication of the DCSO treatment team. Although fidelity indicators such as exposure, dosage, and participant responsiveness were scored high for both programs, adherence to program design was problematic and a function of the turbulent climate characterizing the DCSO jail and its programming throughout much of the grant period. As described above, administrative endorsement of the Second Chance initiatives waxed and waned throughout the life of the study which impacted reentry staff’s ability to ensure adherence to established evidence based practices. Most notable among these was a sheriff’s decision to house treatment participants with the general jail population, thus violating a cardinal rule of correctional rehabilitation (NIDA, 2007). The question remains, however, whether administrative endorsement played a role, either directly or indirectly, in offender recidivism rates observed during the follow-up period. Accordingly, future research might isolate programming outcomes realized during programming junctures characterized by distinct and variable levels of administrative ideological endorsement. Acknowledgments This research was supported by the U.S. Bureau of Justice Assistance, Grant Nos. 2011RW-BX-0008 and 2011-RN-BX0004. The points of view and conclusions are those of the authors and do not reflect the official positions of the U.S. Department of Justice.
Appendix Justice Program Fidelity Scale Site:______________ Rater 1 initials:_____ Rater 2 initials: _____ Date:______________ Rater 1 Adherence (0/1) Intake screening Intake timeliness Treatment plan components Caseload compliance Individualized service plans
Rater 2
Consensus
Actual Value
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Dosage Adherence total: Exposure (0/1) Contact frequency (hours per day) Duration; Program length Exposure total: Delivery quality (coded 1–5)a Staff qualifications Counselor/staff attitude Counselor/staff continued training Delivery quality total: Participant engagement (coded 1–5)b Participant attitude Participant involvement Participation barriers (reverse code) Participant engagement total: Program differentiation (reverse coded 1–5)c Program size fluctuation Program budget fluctuation Caseload fluctuation Continuity of staffing (coded 1–5) Continuity of setting (coded 1–5) Program differentiation total: Total fidelity score
An earlier version of this scale was conceptualized through support from Grant No. 2010-RT-BX-0103 awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice with assistance from Co-Principal Investigator, Dr. Rob Tillyer a Higher scores indicative of greater delivery quality b Higher scores indicative of greater participant engagement c Higher scores indicative of lower program differentiation
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White, M. D., Saunders, J., Fisher, C., & Mellow, J. (2012). Exploring inmate reentry in a local jail setting: Implications for outreach, service use, and recidivism. Crime & Delinquency, 58(1), 124–146. J. Mitchell Miller is a Professor of Criminology at the University of North Florida where he teaches and researches in the areas of drugs and crime, criminological theory, and program evaluation. He is currently conducting mixed-methods program evaluations of offender treatment programs for the U.S. Bureau of Justice Assistance in Louisiana and Tennessee and serves as editor-in-chief of the Wiley-Blackwell Series of International Encyclopedias in Criminology & Criminal Justice. Holly Ventura Miller is an Associate Professor of Criminology at the University of North Florida, a former National Institute of Justice W.E.B. DuBois Fellow, and a Past President of the Southern Criminal Justice Association. Her research interests include correctional policy, program evaluation, and immigration and crime. Recent work has appeared in Journal of Interpersonal Violence, Criminal Justice and Behavior, and Criminology & Public Policy. She is the Editor (with Anthony Peguero) of the Routledge Handbook of Immigration and Crime.
