Providing inmates who have drug problems with intensive drug treatment and postrelease aftercare has a drastic effect in cutting recidivism, according to a compendium of studies published in the September and December 1999 issues of the Prison Journal.

The differences in recidivism are dramatic; in the combined sample of 1,461 inmates from California, Texas, and Delaware, approximately a quarter of those given intensive treatment and aftercare through a therapeutic community ended up back in prison after three years, compared with about three-quarters of those who received either no treatment or treatment in prison without postrelease aftercare.

The potential benefit of intensive treatment with aftercare is staggering: Of the 1,825,000 U.S. residents in jail or prison at the end of 1998, about 65 percent had a history of regular use of illicit drugs, but only 15 percent received any form of treatment, according to the U.S. Department of Justice.

D. Dwayne Simpson, Ph.D., an experimental psychologist and director of the Institute of Behavioral Research at Texas Christian University (TCU) in Fort Worth, analyzed much of the data from the studies and served as the lead guest editor for both issues of the journal.

Aftercare is critical, said Simpson. "If you just treat people in prison and then turn them out," they will relapse. "If you don’t provide some kind of transition and monitoring after release, you are wasting the money spent on treatment in prison," he added.

There is little difference in recidivism between those who are treated in prison only and those who aren’t treated at all, he observed. The conclusion is "that if you don’t provide the whole package, you are wasting your time."

Another key issue is providing effective treatment. One approach popular with politicians and the public—sending drug offenders to boot camp—is totally ineffective, said Simpson.

"The literature from the field has, for some time, not been supportive of the effectiveness of boot camps," he noted. "It’s a punitive orientation that is popular with politicians, but there is no evidence that it reduces recidivism."

Simply throwing people into treatment, however, is not enough, said Simpson. There must be good screening and selection as to who needs treatment, and treatment must be matched to problem severity.

One key finding was that the cost-benefit ratio was most favorable in treating those with the most severe drug-related problems and least favorable for those with the least severe problems. "When you put people who don’t have very severe problems into an intensive therapeutic community, it really doesn’t make much difference" because they are likely to have good outcomes regardless of whether they get services or not, said Simpson.

In contrast, treatment focused on drug-related problems is not effective for dual-diagnosis patients, Simpson added. Those with dual diagnoses "really need other services rather than just drug treatment."

In these studies, severity was rated based on the level of dysfunctional symptoms directly associated with drug use, he explained. Investing in intensive treatment for such individuals provides the greatest return to both society and the individual.

Ideally, treatment should be tailored to the individual, an axiom of psychiatry. But given the dearth of treatment resources, said Simpson, that ideal remains a dream. That dream will not be realized until there is greater political and financial support for the creation of "a treatment system, that is, a full array of services, not just a program," he asserted.

Once patients are appropriately identified and a program exists for them, the next issue is engaging them in treatment. Those who "truly want treatment" benefit the most, he noted. Those who "don’t want to be there, for the most part, don’t really improve."

"This group of studies documents an issue that has become increasingly important in American psychiatry, namely, the emergence of the criminal justice system as an alternative mental health treatment locale," said Richard Suchinsky, M.D., vice chair of APA’s Council on Addiction Psychiatry, in an interview. "The reality is that much of the deinstitutionalization that has occurred has been poorly conceived and in some cases is a sham. What has actually occurred is cost shifting to the criminal justice system, as well as the emergence of a substantial homeless population, a large proportion of whom suffer from substance use and other psychiatric disorders."

TCU’s Institute of Behavioral Research has developed several board games to help patients better understand the consequences of their behavior and their own strengths. The games include one called "Downward Spiral" and another called "Tower of Strength." The National Institute on Drug Abuse is funding further development of the game model. Funding for other aspects of the studies has been provided by the National Institute of Justice.

Information about the studies and the game model is posted on the Web site <www.ibr.tcu.edu>.