Influence of Organizational Characteristics on Success in Implementing Process Improvement Goals in Correctional Treatment Settings.

Although research indicates that organizational characteristics substantially influence the adoption and use of evidence-based practices (EBPs), there has been little empirical research on organizational factors most likely to influence successful implementation of EBPs, particularly in criminal justice settings. This study examined organizational characteristics related to the success of change teams in achieving improvements in assessment and case-planning procedures for persons leaving correctional settings and receiving community services. In this evaluation of the Organizational Process Improvement Intervention (OPII), part of the National Institute on Drug Abuse's (NIDA's) Criminal Justice Drug Abuse Treatment Studies (CJDATS) cooperative, 21 sites were randomized to an early-start or a delayed-start condition. For this analysis, data from both conditions were combined. Agencies with fewer program needs, good communication, adequate staffing levels, good supervision, positive attitude toward rehabilitation, and higher institutional capacity for change were better able to implement planned changes in assessment and case-planning procedures. Such agencies may be better candidates for implementation improvement strategies, whereas other agencies could benefit from pre-intervention efforts aimed at strengthening these characteristics before attempting to improve assessment procedures.

Posttreatment drug use abstinence: does the majority program clientele matter?

The current study examines differences in organizational characteristics and client posttreatment drug use abstinence in residential substance abuse treatment programs serving clients with high or low levels of legal coercion to participate in treatment. The findings show that low legal coercion programs have higher counselor caseloads (Z = 59, p < .05) than high coercion programs. Although the results showed that programs with a large proportion of African American clients (ß = 14.26, p < .0001) and high legal coercion programs (ß = 19.99, p < .05) predicted longer abstinence posttreatment, the final models suggest organizational factors are the key predictors of client posttreatment abstinence.

Motivation and readiness for drug treatment: differences by modality and special populations.

The purpose of this research is to expand our knowledge of motivational factors among admissions to various substance abuse treatment modalities and among those entering special programs. Differences in motivation are reported in a convenience sample of more than 6,000 admissions to 38 programs. Results from multilevel analyses show (a) an ordered increase in motivation by settings from referral to outpatient, to methadone maintenance, and to the highest levels in residential programs and (b) significantly lower motivation among admissions to programs for special populations. Results are discussed in relation to the demand characteristics of treatment and non-recovery reasons for entering treatment.

A cluster randomized trial of an organizational process improvement intervention for improving the assessment and case planning of offenders: a Study Protocol.

BACKGROUND: The Organizational Process Improvement Intervention (OPII), conducted by the NIDA-funded Criminal Justice Drug Abuse Treatment Studies consortium of nine research centers, examined an organizational intervention to improve the processes used in correctional settings to assess substance abusing offenders, develop case plans, transfer this information to community-based treatment agencies, and monitor the services provided by these community based treatment agencies. METHODS/DESIGN: A multi-site cluster randomized design was used to evaluate an inter-agency organizational process improvement intervention among dyads of correctional agencies and community based treatment agencies. Linked correctional and community based agencies were clustered among nine (9) research centers and randomly assigned to an early or delayed intervention condition. Participants included administrators, managers, and line staff from the participating agencies; some participants served on interagency change teams while other participants performed agency tasks related to offender services. A manualized organizational intervention that includes the use of external organizational coaches was applied to create and support interagency change teams that proceeded through a four-step process over a planned intervention period of 12 months. The primary outcome of the process improvement intervention was to improve processes associated with the assessment, case planning, service referral and service provision processes within the linked organizations. DISCUSSION: Providing substance abuse offenders with coordinated treatment and access to community-based services is critical to reducing offender recidivism. Results from this study protocol will provide new and critical information on strategies and processes that improve the assessment and case planning for such offenders as they transition between correctional and community based systems and settings. Further, this study extends current knowledge of and methods for, the study of evidence-based practice adoption and implementation.

A cluster randomized trial of utilizing a local change team approach to improve the delivery of HIV services in correctional settings: study protocol.

BACKGROUND: Persons held in correctional facilities are at high risk for HIV infection and their prevalence of HIV is substantially higher than in the general population. Thus, the need for proper surveillance and care of this high risk population is a paramount public health issue. This study aims to evaluate an organization-level intervention strategy for improving HIV services for persons in prison or jail. METHODS/DESIGN: HIV Services and Treatment Implementation in Corrections (HIV-STIC) is using a cluster randomized trial design to test an organization-level intervention designed to implement improvements in preventing, detecting, and treating HIV for persons under correctional supervision. Matched pairs of prison or jail facilities were randomized using a SAS algorithm. Facility staff members in both Experimental and Control conditions involved in HIV service delivery are recruited to receive training on HIV infection, the HIV services continuum, and relevant web-based resources. Staff members in both conditions are tasked to implement improvements in HIV prevention, testing, or treatment in their facility. In the Control condition facilities, staff participants use existing techniques for implementing improvement in a selected area of HIV services. In contrast, the Experimental condition staff participants work as a Local Change Team (LCT) with external coaching and use a structured process improvement approach to improve a selected part of the HIV services continuum. The intervention period is 10 months during which data are obtained using survey instruments administered to staff members and aggregate services delivery data. The study is being implemented in 13 pairs of correctional facilities across nine states in the US. Experimental sites are hypothesized to show improvements in both staff attitudes toward HIV services and the number and quality of HIV services provided for inmates. DISCUSSION: The current study examines a range of process and outcome data relevant to the implementation of a Change Team approach across diverse correctional settings in the United States. This initial study represents an important step toward a national best practices approach to implementing change in U.S. correctional settings and could serve as an exemplar for designing similar implementation studies.

Racial disparities in substance abuse treatment and the ecological fallacy.

This study examined engagement in treatment in substance abuse treatment programs that treated primarily either African American or White clients. Findings showed higher levels of engagement in White programs; however, engagement of African Americans in White programs was similar to that of Whites and was greater than Whites in African American programs. No significant differences emerged when a mixed model analysis considered additional variables of staff consensus (regarding treatment elements), treatment climate, acceptance of Medicaid clients, the proportion mandated to treatment, and the quality of the physical space. Although African American programs may show poorer levels of engagement than White programs, attribution of engagement in treatment to client level race/ethnicity should be made with caution.

Essential elements of treatment: a comparative study between European and American therapeutic communities for addiction.

The purpose of this study was to investigate whether European and American therapeutic communities (TCs) for addiction, both traditional and modified, share a common perspective on what is essential in treatment using the Survey of Essential Elements Questionnaire (SEEQ). The European sample (N = 19) was gathered in 2009. For the American sample (N = 19), we used previously published research data. Despite comparable perspectives, European traditional TCs (N = 11) scored significantly higher than their American predecessors (N = 11) on four SEEQ domains. Cluster differences were more pronounced in Europe than in America.

Matching to sufficient treatment: some characteristics of undertreated (mismatched) clients.

A previous study by the investigative team using Drug Abuse Outcome Study data supported the validity of a sufficient treatment matching paradigm, which defines successful placement as the least treatment intensity required to address the severity of a disorder. The least favorable outcomes were obtained in the under-treated clients who received insufficient treatment intensity. The purpose of the current study was to further clarify characteristics of the undertreated clients. Four groups, those matched and mismatched to long-term residential (LTR) and drug-free outpatient (ODF) treatment, were compared on several baseline variables. Results indicated that the severity levels of drug use, social and psychological problems, and motivation for those mismatched to ODF (undertreated) were significantly lower than the clients matched to LTR but generally higher than the clients matched to ODF and those mismatched to LTR (overtreated). These findings underscore the importance of identifying clients at risk for under-treatment and facilitating their entry into treatments of sufficient intensity. More generally, they highlight the need to develop a range of treatment options of sufficient intensity to meet severity differences among clients.

Organizational factors and collaboration and integration activities in criminal justice and drug abuse treatment agencies.

Despite strong interest in improving collaborations between correctional and substance abuse treatment organizations, there is a lack of empirical data describing the existing practices. The current study used a national survey of correctional administrators to examine organizational factors related to cross-agency collaboration and integration activities between corrections and substance abuse treatment organizations. Using a measure of collaboration that scaled cross-agency activities from less structured, informal networking and coordination to more structured and formalized levels of cooperation and collaboration, we found that different correctional settings (e.g., community corrections, jails, prisons) differed significantly in terms of their collaborative activities with substance abuse treatment agencies. We also found that the organizational characteristics that were associated with different levels of collaboration and integration differed across the correctional settings. Further research is needed to better understand how and why correctional agencies decide to formalize collaborative arrangements with treatment agencies and whether these efforts lead to more favorable outcomes.

Violent offenses associated with co-occurring substance use and mental health problems: evidence from CJDATS.

The present study examines the relationship between substance use, mental health problems, and violence in a sample of offenders released from prison and referred to substance abuse treatment programs. Data from 34 sites (n = 1,349) in a federally funded cooperative, the Criminal Justice Drug Abuse Treatment Studies (CJDATS), were analyzed. Among parolees referred to substance abuse treatment, self-reports for the six-month period before the arrest resulting in their incarceration revealed frequent problems with both substance use and mental health. For most offenders with substance use problems, the quantity of alcohol consumed and the frequency of drug use were associated with a greater probability of self-reported violence. Mental health problems were not indicative of increases in violent behavior, with the exception of antisocial personality problems, which were associated with violence. The paper emphasizes the importance of providing substance abuse treatment in relation to violent behavior among offenders with mental health problems being discharged to the community.

When goals diverge: Staff consensus and the organizational climate.

A sample of correctional officers and prison substance abuse treatment staff collected by the National Criminal Justice Treatment Practices Survey is used to provide an exploratory study of an aspect of organizational culture consisting of consensus (agreement) among prison personnel regarding their beliefs about rehabilitation in the presence of conflicting organizational goals and aspects of the organizational climate important to change. Findings show that among those staff members responding to the survey, the belief in rehabilitation scale mean score was associated with higher levels of organizational commitment, and interdepartmental coordination. However, an hierarchical linear modeling (HLM) analysis that used an index score derived from the standard deviation for staff consensus regarding these same beliefs about rehabilitation produced a different pattern of results, showing that high levels of consensus were associated with job frustration, cynicism towards the ability of the institution to change, and lower levels of organizational commitment. The authors conclude that, although the sample may not express the beliefs of corrections officers or prison-based treatment staff at large, within the sample, consensus appeared to play a unique role in evaluating the effect of divergent goals on organizational climate as it relates to change, and warrants consideration when considering the effects of organizational climate.

Constructive conflict and staff consensus in substance abuse treatment.

Previous studies demonstrated the relationship between consensus among both staff and clients with client engagement in treatment and between client consensus and 1-year treatment outcomes. The present article explores the correlates of staff consensus, defined as the level of agreement among staff as to the importance of treatment activities in their program, using a national sample of 80 residential substance abuse treatment programs. Constructive conflict resolution had the largest effect on consensus. Low client-to-staff ratios, staff education, and staff experience in substance abuse treatment were also significantly related to consensus. Frequency of training, an expected correlate of consensus, was negatively associated with consensus, whereas frequency of supervision was not a significant correlate. The implications of the findings for future research and program improvement are discussed.

Measuring collaboration and integration activities in criminal justice and substance abuse treatment agencies.

Individuals with substance abuse problems who are involved in the criminal justice system frequently need community-based drug and alcohol abuse treatment and other services. To reduce the risk of relapse to illicit drugs and criminal recidivism, criminal justice agencies may need to establish collaborations with substance abuse treatment and other community-based service providers. Although there are many variations of interorganizational relationships, the nature of these interagency collaborations among justice agencies and treatment providers has received little systematic study. As a first step,we present an instrument to measure interagency collaboration and integration activities using items in the National Criminal Justice Treatment Practices Surveys conducted as part of the Criminal Justice Drug Abuse Treatment Studies(CJ-DATS). Collaboration and integration activities related to drug-involved offenders were examined between substance abuse treatment providers, correctional agencies, and the judiciary. The measurement scale reliably identified two levels of collaboration: less structured, informal networking and coordination and more structured and formalized levels of cooperation and collaboration. An illustration of the use of the systems integration tool is presented.

Client matching: a severity-treatment intensity paradigm.

Despite considerable effort to develop matching strategies and client placement protocols, research studies fail to yield compelling results regarding the benefits of matching to treatment. The most consistent findings suggest a matching paradigm, which defines a successful placement as the least treatment intensity required addressing the severity of the disorder. The purpose of the present study is to provide further empirical support for the validity of a severity-intensity paradigm utilizing data from the Drug Abuse Treatment Outcome Studies. A "passive match" approach employed the Client Matching Protocol decision algorithm, which recommended clients to long-term residential or outpatient drug-free treatment. One-year outcomes for clients matched to long-term residential treatment were better on all outcome variables compared to those undertreated in outpatient drug-free treatment. Findings supported the validity of the severity-intensity paradigm in that undertreated clients showed less improvement compared to matched and overtreated clients.

COD services in community correctional settings: an examination of organizational factors that affect service delivery.

Little is known about service delivery for those in the correctional system with co-occurring mental health and substance abuse disorders (COD). Using data from the National Criminal Justice Treatment Practices survey (NCJTP) on community corrections and jail agencies, this study found that correctional organizations that offer COD services differ from agencies that do not. Organizations that respond to the needs of COD offenders tend to be more "service friendly," rank higher on measures of various dimensions of organizational climate that embrace learning and goal achievement, and tend to adopt more innovations, particularly those classified as evidence-based practices. These survey findings indicate that correctional agencies who serve COD offenders are in a better position to be responsive to the changing service needs of the populations, and are more likely to be able to balance public safety and treatment goals. Future steps to develop support environments for COD assessment and treatment services are discussed in light of these findings.

Gender differences in comorbid disorders among offenders in prison substance abuse treatment programs.

This study examined gender differences in a range of lifetime psychiatric disorders in a sample of 272 offenders newly admitted to a prison substance abuse program. Although these men and women did not differ in severity of substance use in the six months prior to incarceration, women were significantly more likely than men to report a lifetime psychiatric disorder and a lifetime severe disorder. Furthermore, gender differences emerged in the pattern of lifetime psychiatric comorbidity. Women reported greater lifetime major depression, posttraumatic stress disorder, eating disorder, and borderline personality disorder; men were more likely than women to meet criteria for antisocial personality disorder. Additionally, female offenders were found to have a higher degree of internalizing disorders than male offenders, but there were no gender differences in degree of externalizing disorders. The study concluded that women offenders newly admitted to a prison substance abuse program present with a greater psychiatric vulnerability and a different pattern of psychiatric comorbidity than their male counterparts.

Synthesis of studies of co-occurring disorder(s) in criminal justice and a research agenda.

The studies reported in this special issue were designed to take advantage of the unique opportunity that the Criminal Justice Drug Abuse Treatment Studies (CJDATS) cooperative provides to the systematic study of several key issues in programming for co-occurring disorder(s) (COD) in the criminal justice system. These papers present findings from CJDATS studies pertaining to co-occurring disorder(s), identify clinical initiatives to strengthen efforts to treat the population with co-occurring disorder(s), and point to a direction for the elaboration of a future research agenda. Four key areas of investigation are presented: Screening and Diagnosis; the Relationship of Co-Occurring Disorder(s) to Violence; Gender Differences; and the Delivery of Services for Co-Occurring Disorder(s). The first section of this article summarizes the studies included in this special issue within the context of the research literature already available. The second section suggests a future research agenda for the study of offender populations with co-occurring disorder(s), and concludes with a broad statement of clinical advancements to date.

Performance of the CJDATS Co-Occurring Disorders Screening Instruments (CODSIs) among minority offenders.

Previous research has shown the performance of the CJDATS Co-Occurring Disorders Screening Instruments (CODSI-MD and SMD)--six- and three-item instruments to screen for any mental disorder (CODSI-MD) and for severe mental disorders (CODSI-SMD), respectively--to be comparable or superior to other, longer instruments. This study tested the stability of the performance of the CODSI-MD and SMD across three racial/ethnic groups of offenders entering prison substance abuse treatment programs (n = 353), consisting of 96 African American, 120 Latino, and 137 White admissions. The Structured Clinical Interview (SCID) was used to obtain DSM-IV Axis I and II diagnoses; a lifetime SCID diagnosis of a mental disorder or a severe mental disorder was the criterion against which the CODSI-MD and SMD were validated. Results showed no statistical differences in sensitivity or specificity for either the CODSI-MD or SMD across the African American, Latino, and White prisoner groups. The value of the CODSI-MD and SMD as brief screens for mental disorders among offenders with diverse racial/ethnic backgrounds is discussed.

Violent and disruptive behavior among drug-involved prisoners: relationship with psychiatric symptoms.

This study examines the relationship between psychiatric symptoms and violent/disruptive behavior among 192 inmates who participated in prison-based substance abuse treatment. Participants came from two sites able to provide narrative reports of disciplinary actions in the Criminal Justice Drug Abuse Treatment Studies' Co-Occurring Disorders Screening Instrument study. In multivariate logistic models, a lifetime history of thought insertion/control ideation (OR, 11.6; 95% CI, 1.8-75.2), antisocial personality disorder (OR, 3.3; 95% CI, 1.2-8.9), and disciplinary action related to possession of controlled substances or contraband (OR, 4.9; 95% CI, 1.9-12.3) were associated with increased risk for violent or disruptive behavior while in prison, whereas lifetime phobic symptoms (OR, 0.2; 95% CI, 0.1-0.54) and high school graduation (OR, 0.4; 95% CI, 0.2-1.0) were associated with a decreased risk of violence and disruptive behavior in general. We conclude that, among inmates in substance abuse treatment, symptoms that increase risk for violence or disruptive behavior include thought control/insertion ideation and disciplinary infractions related to controlled substances, contraband, or failure to participate in assigned programs, as well a history of antisocial personality disorder.