1. 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

2. 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)

3. 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

4. 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, )
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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. THANK YOU! Steven Belenko, Ph.D. Temple University
Philadelphia, PA, USA
Michele Pich, M.A., M.S.
Rowan Univeristy
Glassboro, NJ, USA