Diversion programs worked, but who can measure how well?

This blog strongly supported initiatives by state Sen. John Whitmire and Rep. Jerry Madden in 2005 and 2007 expanding Texas' treatment and prison diversion programs by a whopping $200 million. Since then, events have unquestionably demonstrated the prescience of those landmark diversion programs, which eliminated the need for new prison building in the short term even though they aren't yet 100% rolled out.

Texans - not to mention Sen. Whitmire and Rep. Madden who shepherded the plan through the Lege - should be proud of that accomplishment, which inarguably saved the state billions of dollars.

It wasn't long ago that official predictions foresaw Texas needing 17,000 prison beds by the end of the next biennium. An additional 17,000 inmates would require issuing bonds to spend billions for several new prisons, plus about $612 million per biennium (at $18K per inmate per year) for staff costs and upkeep. But before the crisis ever materialized, Madden and Whitmire indefinitely forestalled those looming costs by convincing the Lege to invest $200 million per biennium mostly in probation and treatment programs.

I've little doubt diversion programs "worked" because of the dog that didn't bark - Texas prisons would already be bursting at the seams if probation revocation rates hadn't declined significantly in most of the largest jurisdictions.

But if there's one regret I have about Texas' new treatment regimens, it's that the state did not, from the start, establish a mechanism to gather program data for evaluation and improvement. Don't get me wrong - I'm as much to blame as anybody since I and other advocates for diversion programs weren't raising the issue at the time. I'm not assigning blame so much as identifying a shortcoming that still can be fixed post hoc.

I was reminded of this omission before the holiday upon reading a New York Times piece decrying the shortage of "evidence-based" support for many drug treatment programs ("The Evidence Gap," Dec. 22). Reported the Times:

Every year, state and federal governments spend more than $15 billion, and insurers at least $5 billion more, on substance-abuse treatment services for some four million people. That amount may soon increase sharply: last year, Congress passed the mental health parity law, which for the first time includes addiction treatment under a federal law requiring that insurers cover mental and physical ailments at equal levels.

Many clinics across the county have waiting lists, and researchers estimate that some 20 million Americans who could benefit from treatment do not get it.

Yet very few rehabilitation programs have the evidence to show that they are effective. The resort-and-spa private clinics generally do not allow outside researchers to verify their published success rates. The publicly supported programs spend their scarce resources on patient care, not costly studies.

And the field has no standard guidelines. Each program has its own philosophy; so, for that matter, do individual counselors. No one knows which approach is best for which patient, because these programs rarely if ever track clients closely after they graduate. Even Alcoholics Anonymous, the best known of all the substance-abuse programs, does not publish data on its participants’ success rate.

It's not that there aren't evidence-based programs out there, said the Times:

When practiced faithfully, evidence-based therapies give users their best chance to break a habit. Among the therapies are prescription drugs like naltrexone, for alcohol dependence, and buprenorphine, for addiction to narcotics, which studies find can help people kick their habits.

Another is called the motivational interview, a method intended to harden clients’ commitment upon entering treatment. In M.I., as it is known, the counselor, through skilled questioning, has the addict explain why he or she has a problem, and why it is important to quit, and set goals. Studies find that when clients mark their path in this way — instead of hearing the lecture from a counselor, as in many traditional programs — they stay in treatment longer.

Psychotherapy techniques in which people learn to expect and tolerate restless or low moods are also on the list. So is cognitive behavior therapy, in which addicts learn to question assumptions that reinforce their habits (like “I’ll never make friends who don’t do drugs”) and to engage their nondrug activities and creative interests.

Even programs adopted because they're "evidence based" must be rigorously re-tested on an ongoing basis to ensure they continue to be relevant and effective. That's not happening in Texas, particularly since the demise of Tony Fabelo's Criminal Justice Policy Council (victim of a line-item veto by the Governor in 2003). For example, the last outcome study measuring the effectiveness of Texas' in-prison SAFP treatment program was published in 2003.

Even "evidence-based" programs imported from other jurisdictions will require tweaking to make sure they work well in each jurisdiction's unique environment, and the only way to do that is to measure inputs and outcomes in an ongoing fashion.

If Texas is going to spend $200 million plus on prison diversion strategies, it makes a lot of cost-benefit sense to spend at least 1% of that amount on program monitoring and evaluation - not to play "gotcha" with providers who aren't doing well but to identify and promote what works and discard ineffective strategies.

BLOGVERSATION: Scott Greenfield at Simple Justice comments on the Times article.