Monday, December 29, 2008

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.


Unknown said...

Be careful what you wish for. Once these programs have been shown not to work, will the diversion programs be dropped? My own experience with a relative who a has been through programs paid for by the state, prison, by insurance, and out of my pocket is all negative. All of her "friends" who have been through the same programs have the same result.

Gritsforbreakfast said...

Yellowdog, Drug treatment is where a lot of the untested methods lie, especially since many states like Texas haven't embraced the pharmaceutical approaches mentioned like buprenorphine, etc.. Some of the other techniques discussed like motivational interviewing and cognitive behavioral therapy are more well-grounded in research.

IMO, if programs don't work, they should be dropped, drug treatment included. (If only the same criteria were applied to incarceration.) If you can show it improves success rates, I'm for it; if not, why bother?

I'm confident there are enough programs that DO work that there's little danger diversion programs will be "dropped" altogether. They're needed too badly and the state can't afford the alternative.

Anonymous said...

Yes, there is definitely a problem lack of data, but the problem goes beyond that. We also have to keep in mind the level of incompetence of prison officials like Brad Livingston. Don’t get me wrong, he has a difficult job to do, but his administration is not equipped (nor does it want to be) with the necessary knowledge, will, nor the leadership it takes to implement diversions effectively. The only way programs will be properly implemented is if the legislature ties his salary to successful programming or diversion implementation. We have to hold these bureaucrats accountable, not just because they are in charge of money but because diversions are also meant to stop crime and increase public safety.

Anonymous said...

IMHO, we could spend one heck of a lot more money on diversion programs for youth - including mental health treatment. That is a whole lot cheaper than placing them in TYC. (See the figures supplied). TYC should be a last resort, and I think you will find that most thoughtful people within the TYC would agree. I woul love to see it if we not only had diversion programs, but a connection back to those programs for those youth who do end up in TYC. Coordinated efforts at the family leve, the community level, and the institutional level, where necessary, would be so much more effective, and cost effective, as well. O/S

Anonymous said...

I am very distressed that even though the Legislative appropriated millions of dollars for diversion programs and mandated that the State implement these programs, as of today there is very little to show for all the efforts of the Legislature. I do think someone needs to be answerable for this failure to follow the directives of our state representatives. This goes beyond the need for good public policy, it goes to the heart of our democracy. If bureaucrats can refuse to comply with the laws that have been enacted by the people we have elected to office and purposefully thwart legislative intent, and more importantly, if our legislative leadership cannot require them to follow the law then what kind of democracy do we have? It is my understanding that the community justice assistance division (CJAD) of the Texas Department of Criminal Justice was the only entity within TDCJ that seriously tried to implement the diversion programs funded by the Legislature and is the only entity within TDCJ that can show real progress in diverting persons from prison. As in the private section, I do agree that persons in the public sector should only be rewarded based on achieving goals that have previously been established by their board of directors (or, in the case of state government, by the Governor and Texas Legislature).

Anonymous said...

Both adults and youth need treatment.

Unknown said...

Grits, my relative is on suboxone right now ($500/mo). It did help her move from opiates to cocaine. For those who don't know, that's not an improvement.

Anonymous said...

Good Call Grits,

Exactly we need a state wide data base...tracking data. We need each county putting data the same way and to the same areas. The way the funding went out to adult probation was crazy in Bexar. Fitzgerald used the extra officers in all areas of the department and missed the point. You need well trained officers that have a grasp of what Madden and Whitmire are trying to do. We have officers who are data entry officers. We have to double and sometimes tripple enter data because the data entry systems are old as the hills. We have no case management system. Any data you get in Bexar is counted by hand and not tracked properly. If you look at the revocation increase in Bexar you can tell Fitzgerald is in over his head. They are not using the funding correctly. Even if they got the cases down to around 90 cases per officer the turnover is so high you cannot get time to work on motivational interviewing or even trying to figure out who is in front of you.

In Bexar the officers file the Motions to Revoke. So, Monday you come to work and File Motions on arrests from over the weekend, you see some defendants and put out fires the rest of the week filling in for officers who are quiting or call in sick while trying to squeeze in seeing your own defendants.

We know what Madden and Whitmire are doing will work. We need the money used on felony cases not misdemeanor cases but there is room to work on this with misdemeanors through other county funding.
We need a data tracking system and state-wide case management system.

We need officers who will stay more than 5 minutes and get good training. Please come to Bexar and go to some training and you will see they are missing the bus here.
The officers need to spend more than 5 minutes a month talking to the defendants and 25 minutes typing 3 differents reports that are the same. We need to understand what will change the defendants behavior and that will not happen until the caseloads are lower and the officers understand and will remain to carry out the mission.

Some Countys got it right....Bexar missed the whole thing. If the data was tracked all would see where Bexar went wrong instead of Fitzgerald doing more of his same old smoke and mirrors stuff to keep his sorry butt in the chief job.

This will work!!!!!! Just a little more help for the clueless chief in Bexar. Fine tune some areas and we can help the state turn TDCJ into something that will work for all.

Anonymous said...

Evidence based treatment is woefully underused, both in Texas and in the USA in general. For example, methadone treatment is the gold standard of opioid addiction treatment--the most successful method available today--yet only about 10% of those who could benefit from it can access this treatment, and every time a new clinic attempts to open it is met with NIMBY-ism and the tar, feather and pitchfork crowd.

97% of rehabs in the USA utilize the 12 step model of addiction "treatment"--a model that claims great success but in reality is not medically or scientifically based, has not been updated or taken any new findings in addiction science into account in over 70 years, and has been determined by the Supreme Court to be religious in nature, requiring participants to turn over their lives to God, ask God to remove their "character defects", make sin lists and share them with God and others, seek constant contact with God through prayer, etc etc. Participants are sent back to these programs time after time, regardless of how many previous failures they have experienced in this type of treatment, and AA's own internal survey found that only 5% of those who came to AA were still there, sober, one year later.

Science is discovering that addiction is a disease of the brain chemistry, and must be treated as such. This often requires medication, sometimes counseling, and the two methods mentioned--motivational interviewing and cognitive therapy--are a good start. However, the state's premier program for hardcore substance abusers--the SAFP program--utilizes "attack therapy", a form of therapy instituted by Synanon (a California cult) and now almost completely discredited as being harmful to patients, and a heavy sprinkling of 12 step theology and religion.

It's time to leave the pseudo science and religion behind when offering drug treatment therapy.

Anonymous said...

Following this link might provide some insight regarding treatment.
The Authors of the following research reports, Gerald J. Brown and Mark W. Scheeren have a combined 43 years of experience in treatment research. All the authors have written and published articles for international publications and currently oversee many ongoing research projects while providing the most successful methodology for the treatment of substance abusers as directed by responsible research.

Anonymous said...

Sorry, That's Baldwin Research Institute and here's the link;(.cfm not .com)

Anonymous said...

Has anyone thought of taking a look at BPP? There lies a big problem! They do not parole enough people and it cost $49.00/day to house people in prison when a very large number of them should have never been there and have educations and could be paying taxes and not depending on the State to support them. Believe it or not there are many who got railroaded due to the judges, district attorneys who did not care about the lives of those in front of them nor their children and families. Instead they chose to lie and continue to lie just to win.

Texas needs to completely remake the sentencing laws, give good time and work time back to those who deserve it and make the BPP adhere to the rules, which they themselves made, i.e., all protest information is required to be presented prior to a parole hearing and not when someone is due to be released and then revoked. This is horrible and happens to many in Texas.

I ask Sen. Whitmire and Rep. Jerry Madden, to follow their hearts and should the Governor veto a good bill, there are enough votes to override his veto now and hopefully will be enough votes to override him in the next election.

Don said...

Everybody who puts out a "statistic" about their "success" rate has a different definition of success. In criminal justice, it's a "success" that they don't come back to prison within a set length of time. This says nothing of their success in staying sober and leading a productive life, which is the goal of treatment, or should be. If a person is successful using 12-step programs, then 12 step is the singular most successful program in the world, for that person. And it has been for many millions. However, AA in and of itself can't be compared to "treatment" programs, because it is not, and has never professed to be, a treatment program. As a licensed counselor of 20-odd years, many of which were spent in the criminal justice system, I would like to see a program that "works". But the reality is, that it's not the program that "works" or "fails". Addiction is a very complex disease with many aspects and causes, but no cures. It is also very individualized. There is no one size fits all, and there are no programs that have the resources to individualize treatment on such a wholesale basis as the CJ system would require. There is not enough money and/or enough counselors. Plus, treatment is not something that should be under the purview of Criminal Justice in the first place. They are antithetical in nature. Back to AA, the CJ system's "sentencing" people to AA is as bad an idea as you can get, period. There is a readiness involved in 12-step, that cannot be mandated, not by a cop, not by a judge, prosecutor, or probation officer. To add insult to injury, this practice has literally destroyed some local AA chapters. It is a travesty. It is true that some have gone at first because they were forced to, then latched on to the concepts and principles, but you can't send everybody with that hope in mind. What I have found in the rural counties where I have worked, is that CSCD uses AA as a resource, partly because of the lack of other resources, and partly because of laziness. There is no documentation, to speak of. You just tell 'em to go, and get a paper signed. I am for the accountability of treatment programs, but until there is a better way to measure, I don't see how you can have it. Much like the standardized testing done in education, (which also doesn't predict anything), individual differences thwart accuracy. We don't know what drove the decline in the rate of revocations, except they didn't revoke as many people. In 03, when most programs suffered, the way CSCD's got grants was to not revoke as many people to prison. The way to cut down on revocations, in other words, is to, well, don't revoke them. Not a whole lot to it. (Actually, I didn't think of it that way until our probation chief 'splained it to me).

Anonymous said...

If you are doing research on the effectiveness of something, then you generally have a "control group" and a "plecebo group". You hypothesize that a particular type of intervention will yield a particular, measurable result. The intervention must be consistent in it's application. The measurement must be the same for both of the groups, with the major variable being the intervention itself. Sucess in this area is measured in behavioral outcomes, which you would suppose is influenced by both the psychological, physical, and spiritual dimensions of treatment. If we are measuring sucess through measuring a behavior that either increases or decreases in frequency, then we must define that behavior. For instance, in substance abuse it could be reduced alcohol consumption, or a changed pattern of alcohol consumption, or a reduction in problem behaviors related to alcohol consumption such as arrests for disorderly conduct or DWI. This means some type of follow up study over predetermined time periods with both the control group and the placebo group. The biggest problem comes when you try to conduct research while you are ostensibly providing "treatment". The funding sources need to tolerate the research aspect of programs for at least a two year period before coming to any conclusions. Politically, that is a difficult thing to do. However, without a research based pardigm that follows established clinical standards, we will not have a very good chance to show what works and what does not.

Dont Be Denied said...

n fiscal year 2005 and in their own TDCJ staff report, TDCJ's Health Service Division received 5,980 grievance appeals, 22 of which were forwarded to the universities for further investigation of the quality of care provided. A perfect example why these programs are a waste: MRSA staff infection is not a reportable condition in Texas, yet it's listed under "Infectious Diseases." under the Office of Preventive Medicine, Texas Department of Criminal Justice, Huntsville, TX. TDCJ infirmaries will not test infected inmates, but they have the money to swab or blood test them. Now, after the MRSA DEATH cases have risen from 3 people 2001, to almost 4,000 cases of MRSA reported in TDCJ TExas units, the word is out. By September 1, 2009, DSHS will submit a report to the legislature concerning the effectiveness of the pilot program in tracking and reducing the number of MRSA infections. But, if they refuse to diagnose the inmates...whats the point???? TDCJ inmates hav to send send a "sick request" to be seen by a doctor. Now, read my 1st sentence in this letter again.

Don said...

JTP, you make my point. I understand the scientific method of empirical research, but I don't see how you can do it with substance dependence in the criminal justice setting. With all the variables, I really doubt that you can do it very well in any setting.

Anonymous said...

Ching-Ching! That's the sound of money in the pocket of construction contractors (no offense intended to my masonic friends out there) as they reap the benefit of probationer / parolee cheap labor, which lasts for a LONG time... ahhh, the benefits of delegated punishment...

Anonymous said...

Have been on felony deferred adjudication probation for 10 years. Just recently I screwed that up by taking a hit of a joint. Not excusing my stupidity at all. I need help with my addiction to marijuana. Don't believe I should be facing 10 To 20 years for this mistake. I'm not perfect. I have two beautiful daughters. One of two years and the other 5. Me and my fam are praying that one I've these prison diversion programs is considered. When i got my charge I was 18 years old. Possession of a controlled substance back in 2000. I had no clue that by choosing differed adjudication I was damning myself to 10 to 20 years in prison if I ever messed up.had I been properly educated I would have never chosen thi route. Been clean for eight years. I'm facing same time in prison as a murder or rapist. I don't belong in that category. I do agree that these program outcomes should be monitored. I currently seeing a drug counselor for my addiction. I go in today to see what is going to happen. Everyone tells me to prepare to go to jail cause the probation officer I have doesn't send anyone to treatment. Straight to prison they go. God did not give her the power to play with peoples lives like that. Been calling her all week to find out what is going to happen to me and her response is "We are not allowed to discuss these things". Do I tell my boss that I'm going to see my probation officer for lunch and may not return.i have spent over $20,000 on probation,attorney fees, restitution,and drug offenders programs. I don't make enough money to go through t all over again. Something has to be done. I will lose everything if I go to jail for even a year. What is left for me to do when I get out? Be worse than I was when I went in?

R Johnson said...

You make a valid point here. It makes sense to measure success rates based on evidence so that continued efforts can be made to divert inmates into appropriate recovery plans. Evidence shows that buprenorphine treatment is effective in helping addicts recover and should continue to be given as part of a comprehensive treatment plan.