Lisbon Addictions Conference Extrinsic and Intrinsic Factors in Drug Treatment Outcomes for Persons in the Criminal Justice System: The Roles of Motivation and Legal Coercion Steven Belenko Temple University Philadelphia, PA, USA Michele Pich Rowan University Glassboro, NJ, USA Lisbon Addictions Conference Lisbon, Portugal October 25, 2017

Acknowledgments Partial funding for this presentation is provided by the National Institute on Drug Abuse (Grants U01 DA025284, U01 DA036225, R01 DA09075), S. Belenko, principal investigator)

Overview Substance use disorders (SUD) among persons in the justice system Access to effective treatment is limited Principles of effective SUD treatment for offenders Importance of treatment engagement and retention Explore role of motivation in treatment outcomes The constructs of intrinsic and extrinsic motivation, legal coercion A conceptual model for increasing motivation to improve engagement and retention

43% of arrestees at risk for drug dependence (ONDCP, 2016) Adult and Juvenile Offenders Have High Rates of Substance Use Disorders About 80% of U.S. prison and jail inmates had prior involvement with alcohol and/or drugs (Belenko & Peugh, 2005) 43% of arrestees at risk for drug dependence (ONDCP, 2016) 53% of prison inmates meet criteria for drug dependence or abuse (Mumola & Karberg, 2006) 70% of arrested youth have prior drug involvement, with earlier drug initiation than non-delinquent youth (Belenko & Logan, 2003) Co-occurrence of homelessness, unemployment, substance abuse, poor family and social supports

Limited Access to Effective SUD Treatment Only 10% of inmates receive clinical SUD treatment (Belenko & Peugh, 2005), and fewer are linked to community treatment after release (Prendergast et al., 2005; Inciardi et al., 2004) 25% of probationers with histories of drug use receive treatment (Mumola, 1998) Medication-assisted treatment for opiate addiction not generally available in the U.S. criminal justice system (Friedmann et al., 2012) Few youth access drug treatment in the juvenile justice system (Belenko et al., 2017) Short term treatment is ineffective for offenders with multiple co- occurring health and social problems Nationally, only 10% of Americans with SUD are in treatment Factors include lack of public health mission for CJS and JJS, limited incentives for offenders and treatment programs, funding, inadequate treatment infrastructure, organizational and systems barriers Need evidence-based assessment

Principles of Effective Treatment Goals are to reduce relapse and recidivism Requires engagement in, and completion of SUD treatment Initial induction into treatment (2-4 weeks) Engagement in treatment (90 days) Retention in treatment for period long enough to achieve clinical gains (6-12 months?) Reduce relapse Reduce recidivism Improved health Improved social functioning Importance of continuing care, recovery management (McKay, 2012; Dennis et al., 2015; Pelissier et al., 2012) Factors that increase engagement & retention not well understood for offenders

Potential Factors Affecting Treatment Engagement and Retention Induction and Engagement Client characteristics Intrinsic and Extrinsic Motivation Counselor rapport, therapeutic alliance Counseling staff skills Perceived legal pressure Retention Increase in Intrinsic and Extrinsic motivation Program participation (e.g., treatment attendance) Family and friends Behavioral and psychosocial change Simpson & Joe, 2003 Criminal justice contingencies McKay & Weiss, 2005

National Institute on Drug Abuse (NIDA) 13 Principles of Drug Abuse and Treatment for Criminal Justice Populations Addiction is a brain disease that affects behavior Criminal Justice supervision should incorporate treatment planning for drug abusing offenders, & treatment providers are aware of correctional requirements Recovery requires effective treatment followed by managed care over time Treatment must last long enough to produce stable behavior change Continuity of care is essential Assessment is the first step for drug abusers re-entering the community Treatment should be tailored to fit needs of the individual Rewards and sanctions encourage pro-social behavior & treatment participation Drug use during treatment should be carefully monitored Treatment should target factors that are associated with criminal behavior Bolded principles relate to treatment process, and can be affected by motivation

NIDA’s 13 Principles of Drug Abuse and Treatment for Criminal Justice Populations (continued) Integrated treatment for offenders with co-occurring disorder should be considered Medications are important part treatment for some offenders Treatment planning for drug abusers in the community or re-entering should include treatment & prevention of medical conditions

Evidence-Based Treatment Principles to Reduce SUD Among Offenders Assessment and services addressing multiple needs, dynamic risk factors Including assessment for intrinsic and extrinsic motivation levels and influences Continuing, adaptive care from institution to community Target criminogenic risk factors

Evidence-Based Interventions to Reduce SUD Among Offenders Cognitive-behavioral therapy Motivational Enhancement therapy Contingency Management Prison Therapeutic Communities with continuing care after release Family-focused interventions for youth Medication Assisted Treatment Drug Courts targeting high-risk offenders Trauma-informed care

Motivation for Treatment Both intrinsic and extrinsic motivation may be important for positive treatment outcomes but these constructs need further development Intrinsic motivation Perceived locus of causality Self-acknowledgment of the SUD (problem recognition) Interest in reducing drug use (internalization of drug using behaviors) Desire to improve one’s life circumstances Person enters treatment for reasons he or she finds meaningful Extrinsic motivation Legal “coercion” Family pressure, peer pressure Employer pressure These constructs not always well defined Theoretical and empirical research has noted the roles of both intrinsic motivation and extrinsic motivation), but these constructs have not been well defined and it is not clear how they interact in different individuals and settings. One traditional axiom of substance abuse treatment has been that clients needed to be "motivated" to change in order to reap the maximum benefits of treatment. Indeed, several prominent theories of behavioral change (see below) posit that individuals need to reach a certain level of readiness to change, or motivation, before being able to successfully engage in the therapeutic process

Motivation Construct The constructs of intrinsic and extrinsic motivation May interact and vary in different individuals and settings Change naturally over time, and can be changed with interventions Progressive stages of cognitive or psychological commitment Transtheoretical Model of Change IProchaska & DiClemente, 1983) Motivation is a complex, dynamic, multi-dimensional construct that varies among individuals, treatment settings, and contexts Intrinsic motivation may be low at the initiation of treatment, but increase over time; client begins to internalize the value of treatment for maintaining recovery Extrinsic motivation in the form of legal coercion to engage in treatment does not necessarily function in the same way for all individuals, and may vary over time and context High pretreatment motivation may predict better therapeutic alliance, attendance, perceived counselor competence Problem recognition, desire for help, treatment readiness are other concepts that have been proposed, related to motication

Legal Coercion Many criminal justice-based treatment interventions can be viewed as “coercive” Mandated treatment in prison Judicial-ordered treatment Drug Courts Threat of negative consequences or punishment for noncompliance But how an offender perceives the legal pressure is important as well In prior research we have found that Perceived Legal Pressure affects treatment outcomes (Young & Belenko, 2002) Offenders vary in how they perceive the nature and level of legal coercion Understanding of the consequences of treatment failure Are behaviors monitored by CJ agents? Are legal conditions enforced? Severity of the consequences for violating legal mandates PLP based on deterrence theory CJ agencies should clearly inform offenders about consequences of treatment dropout, and enforce sanctions Coercion measures should be multidimensional (e.g. psychological factors, cognitive abilities) Non-legal coercion

Two Contrasting Models Portugal decriminalization model with Dissuasion Commissions Recognize importance of motivation Use of motivational interviewing to increase motivation and move drug user into later stage of change Referral to drug treatment but no initial coercion Mild sanctions may be imposed for noncompliance American model: focus on coerced treatment Treatment in prisons and jails Mandated treatment under probation and parole Drug treatment courts Prosecutorial diversion Regular monitoring and drug testing Severe consequences for relapse or noncompliance with treatment, including incarceration

Perceived Legal Pressure Interactions Between Intrinsic and Extrinsic Motivation, and Treatment Success Perceived Legal Pressure External Motivation Internal Motivation Low Medium High * ** *** These levels vary over time and can increase or decrease during different phases of treatment Interventions such as MI can increase intrinsic motivation Perceived legal pressure can affect both types of motivation These interactions may vary depending on treatment phase, but also by individual, clinical staff, CJ staff. and contextual factors *Low probability of treatment completion **Moderate probability of treatment completion ***High probability of treatment completion

Conclusions Successful SUD treatment outcomes may requires both intrinsic and extrinsic motivation, and treatment interventions can be tailored to maximize these factors Non-linear model of treatment outcomes Need to properly conceptualize and measure various aspects of intrinsic and extrinsic motivation Offenders should be assessed for intrinsic motivation levels at beginning of treatment and periodically thereafter

Conclusions Extrinsic motivation can be monitored and modified as well Family Friends Employer Effects of motivation and coercion may be time-dependent and reciprocal Treatment process (including process of initiation) and environment may affect outcomes The effects of coercion from the criminal justice system depends on how these contingencies are perceived by the offender Effective SUD treatment interventions for offenders increase public safety and public health

THANK YOU! Steven Belenko, Ph.D. Temple University Philadelphia, PA, USA sbelenko@temple.edu +1 215 204 2211 Michele Pich, M.A., M.S. Rowan Univeristy Glassboro, NJ, USA pich@rowan.edu +1 856 256 4669