Drug Treatment in Prison : An Evaluation of the RAPt Treatment Programme [1 ed.] 9781906534127, 9781872870267

Citation preview

TPS (216mmx148mm)

ISBN: 01-872-870-26-0 (216mmx148mm) (210)

Drug Treatment in Prison AN EVALUATION OF THE RAPt TREATMENT PROGRAMME

Carol Martin is a research officer at the Centre for Criminological Research, University of Oxford. She has worked within the criminal justice field in both a professional and lay capacity for 20 years. Her previous research has included conflict and violence in prisons, drug use and drug treatment in prisons, 'Scared Straight' programmes, prison Boards of Visitors and young and juvenile offenders. She is the editor of the ISTD Handbook of Conll11unity Progranlnles for Young and Juvenile Offenders (Waterside Press, 1998). Elaine Player is Reader in Criminology and Criminal Justice at the School of Law, King's College London. Her previous publications include Grendon: A Study of a Therapeutic Prison (Clarendon, 1995); Prisons After Woolf: Refonn Through Riot (Routledge, 1994); Race Relations in Prisons (Clarendon, 1989).

Drug Treatment in Prison AN EVALUATION OF THE RAPt TREATMENT PROGRAMME

Carol Martin is a research officer at the Centre for Criminological Research, University of Oxford. She has worked within the criminal justice field in both a professional and lay capacity for 20 years. Her previous research has included conflict and violence in prisons, drug use and drug treatment in prisons, 'Scared Straight' programmes, prison Boards of Visitors and young and juvenile offenders. She is the editor of the ISTD Handbook of Conll11unity Progranlnles for Young and Juvenile Offenders (Waterside Press, 1998). Elaine Player is Reader in Criminology and Criminal Justice at the School of Law, King's College London. Her previous publications include Grendon: A Study of a Therapeutic Prison (Clarendon, 1995); Prisons After Woolf: Refonn Through Riot (Routledge, 1994); Race Relations in Prisons (Clarendon, 1989).

11

Drug Treatment in Prison

Drug Treatment in Prison An Evaluation of the RAPt Treatm.ent Program.m.e Published 2000 by

WATERSIDE PRESS DomumRoad Winchester 5023 9NN Telephone or Fax: 01962 855567 E-mail: [email protected] Online catalogue and bookstore: www.watersidepress.co.uk ISBN 1 872 870 26 0

Copyright: Carol Martin and Elaine Player. The format and design are the copyright of Waterside Press. All rights reserved. No part of this book may be reproduced, stored in any retrieval system or transmitted in any form or by any means, including over the Internet, without prior permission. Catalogue-In-Publication Data: A catalogue record for this book can be obtained from the British Library Printing and binding: Antony Rowe Ltd, Eastbourne Cover design John Good: Holbrook Ltd, Coventry Cover photographs: The Rehabilitation of Addicted Prisoners Trust (RAPt).

Print-on-demand edition First issued January 2003

Drug Treatn1ent in Prison iii

Drug Treatment in Prison AN EVALUATION OF THE RAPt TREATMENT PROGRAMME

Carol Martin

Elaine Player

WATERSIDE PRESS WINCHESTER

iv Drug Treatment in Prison

Drug Treatment in Prison v

Drug Treatment in Prison CONTENTS Acknowledgements vi

Introduction 7 Chapter

1 2 3 4 5

6 7 8

Research Design 9 The RAPt Programme 17 The Original Sample 26 Post-release Experience 36 Drug Use Post-Release 42 Criminal Behaviour 58 Interpreting Programme Effectiveness 71 Summary of Main Findings 79

Appendices I

11 III

Comparative Data for Original Sample, Sub-Sample and Reconvicted Sample 86 Miscellaneous Tables 90 The 12 Steps 92

Bibliography 93 Index of Tables 95

vi Drug Treatment in Prison

Acknowledgements We gratefully acknowledge the help we received from many quarters during the passage of this research. In particular, we would like to thank Sarah Salmon who undertook most of the interviewing and the tracing of respondents after their release from prison, together with much of the data entry. We are grateful to the staff at the Centre for Crime and Justice Studies (formerly the Institute for the Study and Treatment of Delinquency) in the School of Law, King's College London for their patience in the administration of this project. The former Director of ISTD, Julia Braggins and Julie Grogan were particularly encouraging and facilitated its smooth running. We benefited considerably from discussions with Mike Trace, then Director of RAPt, when initially designing the research programme and we are grateful to his successor Adam Sampson for his continued interest and support. The RAPt staff in the individual prisons assisted in organising the interviews and individual members of prison staff also played important roles in facilitating access to prisoners and to prison records. We owe a debt of thanks to everyone who helped ill the tracing of prisoners after their release. This included RAPt staff, staff at HM Prison Service headquarters and in individual prison establishments, probation officers and friends and families of the men we were seeking. Finally, thanks to the men who took part in the study for their co-operation with the interviews and for tolerating the intrusiveness of our inquiries. Carol Martin Elaine Player September 2000

Introduction This report details the findings of a two-year study into the effectiveness of the RAPt drug treatment programme which has been operating in a number of male prisons in the south-east of England. Initially, the aim of the research was narrowly defined as being: • To evaluate the effectiveness of the RAPt treatment programme in enabling male prisoners with self-confessed problems of substance misuse to lead a drug and alcohol-free life, both in prison and in the community after their release. Subsequently, after the fieldwork had been completed, an additional aim was accommodated: • To assess whether the completion of the RAPt drug treatment programme is associated with a reduction in the likelihood of reconviction post-release. The purpose of this report is to provide a digestible account of the main findings that emerged from this highly focused empirical work.

BACKGROUND TO THE STUDY 0.1

The history of this research began five years ago. In 1994/5 the authors carried out a preliminary evaluation of the ADT (Addictive Diseases Trust) programme at HMP Downview for the Prison Department. ADT (as RAPT was formerly known) was the first therapeutic programme exclusively for drug and alcohol misusers to operate in a prison in England or Wales. The programme was innovative and was based on a residential adaptation of the '12 Step Minnesota Model' that requires total abstinence from drugs and alcohol for its participants.

0.2

The Prison Department commissioned the research to ascertain information in four key areas: • a detailed description of the programme • its accommodation within the prison environment • the effectiveness of the programme in reducing drug and alcohol use in prison; and • guidance for the development of further research to assess the longer term effects of treatment.

8

0.3

Drug Treatnlent in Prison

At the time of the preliminary evaluation, it was envisaged that a two year outcome study would follow, to examine the performance of the programme in terms of its participants' drug/alcohol use and offending behaviour post-release. However, due to changes in personnel and research priorities in the Prison Department, that follow-up study was never commissioned.

0.4 The Chief Executive and Board of Trustees at RAPt understood, nevertheless, that the long-term future of their programme within penal establishments in England and Wales depended on independent evidence of the programme's effectiveness. Accordingly, they invited tenders for a research contract to carry out the original evaluation.

CHAPTER 1

Research Design 1.1

Evaluating the effects of a particular therapeutic intervention is a highly complex and ultimately imprecise task, primarily because it is so difficult to control for the multitude of intervening factors that could influence any particular outcome. How can a researcher be sure that the observed changes in a person's behaviour are due to a particular therapy rather than to something else? Clinical trials in bio-medical sciences provide greater opportunities than are usually available to social science researchers to manipulate and control the research environment and, in consequence, to speak with greater authority about 'cause and effect'. Yet even here the conclusions reached are conditional probabilities rather than absolute certainties. In consequence, the methodology of the present evaluation could not prove that RAPt is effective in reducing problem drug use and drug-related criminal behaviour, although it could disprove its claim to effectiveness. The best that this, and any other project of its kind, can achieve is to indicate the likelihood of a positive therapeutic effect.

1.2 The obvious starting-point for an evaluation of this kind is to compare a population of drug misusers' who have experienced the RAPt programme with a matched population which has not. But on what factors should the two populations be matched? At a fundamental level, basic demographic factors and the extent and nature of their drug use should be broadly similar as should the individuals' motivation to change and the length and severity of their criminal record. But even assuming similar patterns of druguse, motivation and criminal careers, can it be assumed that any observed differences in the post-release behaviour of the two groups are due to the exposure, or lack of such, to RAPt? Aside from any therapeutic intervention there are numerous factors potentially affecting whether someone in prison will return to, or abstain from, drug use and criminal activity after their release. The level of their support from relatives and friends; the accessibility of their drugs of choice; and the opportunities they have, and the good fortune they experience, in establishing an alternative lifestyle, are only some of the variable circumstances that shape each person's 1 The

term drug misuser' includes alcohol misusers unless specifically excluded. I

10

Drug Treatment in Prison

lived experience. Clearly these vicissitudes of life cannot be controlled in advance to provide a more ordered research environment. Unlike the framework of the clinical trial, the social science model adopted here must work in the laboratory of the real world. 1.3

With these methodological issues in mind a series of practical objectives were set which established a framework for the empirical research. These were to: • contact a sample of male prisoners with problems of drug and/or alcohol dependence, all of whom would have sought treatment from RAPt but only some of whom would have attended the programme • identify their drug-using histories and patterns of use • follow-up a sub-sample six months after their release and reexamine their drug use and criminal behaviour; and • compare the post-release experiences of those who had graduated from the therapeutic programme with those who had not.

RECRUITMENT OF THE SAMPLE 1.4

The research focused on a sample of 200 male prisoners all of 2 whom considered their substance use to be problematic. They were selected from the four male prisons in London and the southeast where a RAPt programme was operating: HMPs Downview, Coldingley, Pentonville and Wandsworth. 3 The sample was divided into three cohorts (see Table 1.1): • graduates-men who had completed the RAPt programme according to the criteria applied within their establishment • drop-outs-men who had begun the programme but had left early, for whatever reason

2

3

One inmate identified gambling as his 'problem substance'; for the purposes of this study he regarded himself and was regarded by the researchers as any other 'substance misuser'. There was one other prison where RAPt had just established a programme at the commencement of the research, HMP Norwich. The newness of the venture at Norwich meant that it was not considered suitable to be part of the evaluation.

Research Design

11

• non-starlers-men who had applied to join RAPt, some of whom had spent lengthy periods on the 'pre-admission groups', but had not started the actual programme, for whatever reason

Per cent

Status

Number

Graduates

95

47.5

Drop-outs

35

17.5

Non-Starters

70

35

Total

200

100

Table 1.1: The original prison sample by treatment status

1.5 The fieldwork was carried out between August 1997 and August 1999. It had originally been scheduled for completion in June 1999, which meant that only inmates likely to be released before November 1998 would have enough time post-release to qualify for inclusion in the research. The difficulties of identifying sufficient numbers of men with appropriate release or parole dates led to an extension of the fieldwork period by two months and some restructuring of the original sample to include ten men with release dates that fell within the six month cut-off period. 1.6 It was explained to each man invited to take part in the study that their participation involved being interviewed in prison and then again in the community about six months after their release. It was made clear that their involvement in the research was entirely voluntary. 1.7

Graduates and drop-outs were approached for interview as soon as they had graduated or left the programme. Non-starters were identified from the pre-admission lists in each prison and were interviewed as soon as it was known that they would not be starting the course. The decisions regarding the latter group were made by RAPt staff operating the programmes in each prison.

1.8

The reasons for inmates not starting the course varied between the different prisons. At Pentonville and Wandsworth, local , prisons, most of those on the pre-admission lists who did not start the programme were serving sentences too short to accommodate the length of the course. Whereas at Downview and Coldingley,

12

Drug Treatment in Prison Category C training prisons, the non-starters tended to be inmates who had changed their minds about embarking on the programme after they had experienced the pre-admission group. At both of these establishments there were substantially fewer non-starters than at the local prisons. In Downview, particularly, there was a strong incentive to stay on the pre-admission group and wait until a place on the course became available, even though the preadmission group was large and they might have to wait several months to begin the course. This was because Downview, the only Category C prison within the Greater London area, was much in demand by those inmates who lived locally and received visitors from the London area. Similarly, applying for a transfer to the RAPt course at Downview was one way for inmates from the London area to facilitate an allocation closer to home. If, however, an inmate who had transferred for that reason did not begin the course, he would be sent back to his prison of origin.

1.9

The amount of time the researchers spent in each of the four prisons was determined entirely by the availability of potential interviewees. The numbers recruited to the sample varied between the different establishments (see Table 1.2). The difference in contribution to the sample made by the different institutions was not by design; inmates were interviewed as and when they qualified for inclusion in the study, irrespective of the prison in which they were located. Number

Per cent

Downview

46

23

Coldingley

30

15

Pentonville

91

45.5

Wandsworth

33

16.5

Total

200

100

Prison

Table 1.2: Sample size by prison

1.10 It was anticipated that contacting many of these men in the

community would be difficult and that the attrition rate would be high. The aim was to follow-up a sub-sample of 100 men, roughly half of which would be graduates.

Research Design

13

1.11 Following their release, letters were sent to all former inmates in the

sample, reminding them of their previous participation in the research and asking them to contact the researchers to arrange a final interview. Those who did not respond to the first letter were written to again and if their telephone numbers were known they were called as well. A small fee was offered for participation and travel costs were reimbursed; these conditions did not, however, apply to men who had returned to prison.

1.12 The researchers called, unannounced, at the homes of ten men who had addresses in the London area. This tactic, however, was abandoned as it proved time consuming and resource intensive and resulted in only one interview. There was also the ethical consideration of whether pursuing subjects who had been given several opportunities to respond, but had decided not to do so, could be construed as harassment. It was therefore decided to discontinue attempts to contact men whose addresses were known but who failed to respond to earlier requests by letter or telephone. 1.13 By the end of the fieldwork a sub-sample of 75 men had been reinterviewed (see Table 1.3). These interviews took place in a number of locations: nine different prisons, in their own homes, in the homes of family members, in a drug rehabilitation centre and at the researchers' offices at King's College London. Three men were living long distances from London and were re-interviewed over the telephone. Since the conclusion of the study three men have made contact to try to arrange an interview.

Status

Number

Per cent

Graduates

42

56

Drop-outs

13

17

Non-Starters

20

27

Total

75

100

Table 1.3 : The sub-sample by status

14

Drug Treatn1ent in Prison

THE RESEARCH INSTRUMENTS 1.14 The research instruments were three structured questionnaires, all of

which were completed manually by the researchers. The first two were intended to be used in prison and the t11ird, post-release, in the community. 1.15 Questionnaire one collected both qualitative and empirical data on

demographic profiles; criminal histories; drug and alcohol use both inside and outside prison; prison disciplinary records; reasons for applying to, leaving early from, or not starting RAPt; perceived effects of the programme; and interviewees' hopes and expectations for the future. 1.16 Questionnaire t'lVO, a much shorter questionnaire, was designed for

use immediately prior to release. This included questions about whether family and friends used drugs or alcohol and asked for vital post-release contact details. The purpose of this questionnaire was to attempt to maximise contact with the sample, partly by seeing them again just before release to remind them of the research and partly by ensuring that the researchers had the most up-to-date information about their post-release plans. 1.17 Questionnaire three focused on what had happened to the men post

release. Data were gathered on their pattern of drug/alcohol use; the incidence of re-offending; their material circumstances; their contact with other drug/ alcohol misusers; their family relationships; whether they had contact with any help / support groups; and whether they had experienced any lifestyle changes.

PROBLEMS ENCOUNTERED 1.18 The researchers had known that contacting released prisoners in the community would be difficult. In this case, a population of former prisoners all of whom had been, and some of whom still were, drug and alcohol misusers, added to the complications. Furthermore, the vast majority of this sample were men who were not released under supervision or licence that lasted longer than six months, so the possibility of enlisting the help of various Probation Services in all but a very few cases was not an option. 1.19 Throughout the fieldwork period, liaison between the researchers

and RAPt staff was crucial in identifying men eligible for inclusion in the sample. Despite a large degree of co-operation, an unknown

number of potential interviewees were lost to the study as,

Research Design

15

understandably, the priority of RAPt staff was to deliver the course, not to keep the researchers informed of changes in participants that occurred within individual prisons. 1.20 A research design that incorporates an official mechanism for

following-up such a sample is clearly advantageous in increasing the potential response rate. In the present study the level of attrition was tolerable but would undoubtedly have been lowered had there been an established line of contact in the community. On the other hand, it might be argued that the absence of an official link enabled the researchers to be viewed as independent and encouraged those men who did participate to adopt a more candid approach to the interviews. There is, however, a risk that the sub-sample is biased in favour of those who have more stable lifestyles and who are therefore, more contactable. 1.21 A number of the sample had no fixed address on release and their

whereabouts were unknown to (or were not disclosed by) those living at their contact addresses; some letters were returned undelivered or unopened. Two men had left the country to live abroad. Some of the men made appointments to be interviewed but did not turn up and one man telephoned to decline any further part in the study. Sadly, one of the original respondents committed suicide shortly after his release from prison.

VERIFICATION 1.22 Information supplied by inmates was verified wherever possible.

Each inmate's individual prison record was scrutinised to confirm current offence, previous convictions and custodial record, and prison disciplinary record. 1.23 Ideally drug tests would have been conducted on all the men interviewed in the follow-up sample. The cost of this was, however, prohibitive. It was therefore decided that at the post-release stage, only former inmates who said that they had not used their drug of choice since release were tested. 1.24 Those for whom alcohol had been their drug of choice were asked to give a breath test using a Lion intoximeter on loan from the Metropolitan police. Where the drug of choice had been heroin, other opiates or cocaine the men were asked to provide a sample of hair for testing which was cut by the researchers and sent to Tricho-

16

Drug Treatn1e11t i11 Prison

Tech in Cardiff for analysis. 4 Men whose hair was not long enough for testing were asked to provide a urine sample, which was tested by the researchers. Two men declined a hair test, one on religious grounds who gave a urine sample instead; and the other declined any test. Where appropriate, urine samples were also used to test for cannabis. 5 1.25 The re-offending behaviour of the original sample of 200 men was

examined in relation to data held on the Home Office Offenders' Index. This revealed the number of men convicted of any offence since their release from prison. It also provided information about the types of crimes and the sentences imposed.

4

5

The testing procedures were able to show whether these drugs had been used during a given period of time, but they did not reveal the frequency or extent of use. The period of time covered by the tests depended on the length of the hair sample: one centimetre of hair represented one month. The usual test period was three months. See Appendix Il, Table 2.

CHAPTER 2

The RAPt Programme 2.1

RAPt offers a 12 Step programme of recovery for alcoholics and drug addicts; in the past, it has also dealt with compulsive gamblers. Initially established in HMP Downview in 1992, it currently operates in seven establishments in England and Wales. These comprise five adult male prisons, one male young offender institution and one female prison. 1

2.2

In each establishment the arrangements for the delivery of the programme differ according to the physical structure of the prison. A unifying feature is that RAPt occupies discrete space designated for its own exclusive use. In Downview this consists of two portakabins, whereas in Wandsworth the programme is run from wing accommodation.

2.3

The programmes are run by staff employed by RAPt, the majority of whom are recovering addicts/alcoholics with at least three years clean time; some may have a previous criminal and custodial record. In addition to the paid staff there may also be members of the staff team working on a voluntary basis. All of them are qualified counsellors; however, in some cases, RAPt may seek to employ individuals in the latter stages of their training who have a knowledge of recovery issues. The size of the RAPt team varies in each establishment, from ten in HMP Downview to three each in HMPs Reading and Littlehey.1n most establishments prison officers work alongside RAPt staff and participate in as much therapeutic activity as their training and availability allows. There are, however, aspects of the programme which are delivered only by fully trained and experienced counsellors. Finally, in every establishment but one there are between two and seven 'peer supporters' who take an active part in the treatment process. These are serving prisoners who have successfully graduated from the programme and who have been assessed as suitable to work in the RAPt unit instead of being allocated to one of the usual work parties in the prison

1

RAPt currently operates in: HMPs Downview, Coldingley, Norwich, Wandsworth, Reading, Littlehey and Send.

18

Drug Treatment in Prison

ACCESS TO THE PROGRAMME 2.4

Any inmate can apply for a place on the treatment programme. If a prisoner is not already accommodated in a prison where RAPt operates he or she can apply for a transfer. Since the advent of the Prison Service CARAT (counselling, assessment, referral, advice and throughcare) system, applicants are now usually required to have the support of a CARAT worker in order to gain access to a RAPt programme. 2

2.5

Once a RAPt staff member has received the application, a prisoner will undergo a detailed assessment process to determine his or her suitability, including face-ta-face interviews and the use of accredited assessment tools. The criteria for full acceptance are that the person is severely drug dependent, has a history of failing to control their use, has some propensity to multi-substance abuse and that there is evidence of a link between their drug use and their offending. Beyond this, the prisoner must have enough time to serve to complete the course and he or she must be currently abstaining from all mood-altering substances in order to access the primary programme.

FUNDAMENTAL PRINCIPLES 2.6

The RAPt course of treatment is based upon a programme developed in Minnesota in the 1950s.3 It is predominantly a 12 Step programme but it combines elements from various treatment models, such as the therapeutic community, group therapy and individual counselling, as well as some cognitive strategies of behaviour modification.

2.7

Its specific philosophy of intervention is based upon two major premises. First, RAPt believes that, for an individual addictsomeone who has severe physical and psychological dependencethe condition of addiction is usually irreversible. For addicts, controlled use is unlikely ever to be possible and the aim of

CARATs (Counselling, Assessment, Referral, Advice and Throughcare) is a drugs service introduced into every prison in England and Wales in October 1999. Usually provided by a mixture of uniformed prison officers and external drugs workers, it aims to provide basic information for drug users and link those with more serious problems to appropriate services inside or outside prison. 3 For an historical account of the Minnesota experience see Anderson, D. J. (1981), Perspectives on Treatl1l~llt: The Minnesota Experience, Minnesota: Hazelden Foundation.

2

The RAPt Programnle 19

treatment must therefore be to manage, rather than cure, the problem, so that individuals are able to cope with their condition. 2.8

Second, RAPt believes that, because addicts are at risk of crossaddictions, readily substituting one substance for another, the only viable route to recovery is a lifestyle based upon abstinence from all mood-altering drugs. For individuals whose primary drug of choice is heroin, for example, RAPt would suggest that they abstain not only from using heroin but from using all drugs, including alcohol.

PROGRAMME DESIGN 2.9

The programme is structured as a rolling programme of treatment, with newer members joining as older participants leave. In some projects, the programme is run in one single residential setting, with participants on any phase of the programme housed together in discrete accommodation that separates them from the rest of the prison. In others, only those engaged in primary treatment are housed together. In yet others, participants on the programme are not held in separate accommodation at all but reside in any part of the prison. Whatever the setting, in every RAPt project there are three phases of treatment: pre-admission, primary and aftercare.

Pre-admission 2.10 Pre-admission, which is more properly known as Assessment, Education and Pre-admission (AEP), was originally developed in order to deal with the fact that there is a waiting list for the RAPt courses in every prison. However, it has now become a necessary phase of treatment in its own right. Pre-admission has three aims: to provide basic information about addiction, drug awareness and health promotion; to provide an opportunity for detailed assessment of individuals' suitability for the primary programme; and to prepare potential participants for what they can expect from primary treatment. 2.11 The precise nature of the pre-admission phase varies from project to project. At a minimum, prisoners will attend at least two preadmission groups per week, consisting of a mixture of didactic teaching and group work. The participants are shown videos that explain the principles upon which the programme is based, or they may have a guest speaker, and they are encouraged to discuss the issues that arise from these in relation to their own experiences of addiction. In addition, they are expected to attend support meetings

20 Drug Treatment in Prison

held in the prison by outside bodies such as Alcoholics Anonymous or Narcotics Anonymous. 2.12 Pre-admission also provides an opportunity for RAPt staff to carry out a detailed assessment of an individual's suitability for the programme. In recent times, the assessment process has been formalised to ensure that only those who fit the criteria for the programme are accepted. This is done by the use of a battery of measures, including DSM4 and the Christo Drug Inventory adapted specially for use in RAPt units. These formal measures are supplemented by judgements formed by observation of potential participants throughout the pre-admission process. During the period covered by the present research the assessment process was considerably less formal, in that psychological tests were not administered and the evaluation of a person's suitability for treatment was primarily based on the level of motivation they demonstrated during exercises on the pre-admission group. 2.13 During the pre-admission phase inmates are expected to abstain from all drug-use. Failure in this respect, however, may not always result in expulsion from the group, although it may lead to an individual losing his or her position on the waiting list and thereby delay access to the programme. The emphasis at this stage is on encouragu1g and testing each inmate's motivation to change. 2.14 It is not uncommon to find prisoners on the pre-admission group with insufficient time to undertake the primary programme. These inmates are allowed to remain on the pre-admission group and may be given advice and assistance to access treatment after release. Primary treatment 2.15 Unlike the pre-admission phase that may vary from one prison to another, the elements of the primary programme are now standard. The numbers in treatment may vary, from time to time and project to project: Reading and Littlehey each have a maximum capacity of 12 participants, whereas Downview's capacity is 36. In each case, however, individuals will be assigned to a group containing no more than 12 participants at anyone time. The length of treatment is normally 12 weeks, although this can be extended for a week or two if necessary to enable an inmate's full completion. At the time the research was conducted the standardisation of the programme was less developed and there was greater variation in the length of the programmes in the different establishments and in the number of steps that were completed before graduation from the primary programme.

The RAPt Programnle 21

2.16 The content of the programme is structured by two primary

treatment strategies: the 12 Steps and the therapeutic community (TC). The programme does not, however, adhere strictly to the ideal model of a therapeutic community, due mainly to the absence of discrete accommodation in all participating prisons. Unlike other prison-based therapeutic communities occupied by inmates for 24 hours a day, seven days a week, such as that at HMP Grendon, the RAPt rc is formally limited to working hours within a five-day week. The continuity of the programme is however extended beyond the time inmates spend in the RAPt units by the requirement that specific course-work is completed by participants in their free time. Despite the vagaries of the accommodation the programmes are able to demonstrate many attributes of the Te model. Each participant becomes a member of the therapeutic community and must accept the responsibilities and duties that go along with that membership. Before being admitted they are required to sign a contract, agreeing to accept certain rules and conditions. For example, they are required to reside in one of the substance-free wings in the prison; to attend at least two support meetings each week, run by AA or NA; to abstain from all drug use; and to agree to random urine analysis during treatment. They are also required to participate in regular community meetings and goals-groups, where community issues are discussed and individuals are given feedback from their peers about their own behaviour. Finally, there is at least a degree of separation between those in treatment and other inmates in the prison, to the extent that the RAPt programme is regarded as a full-time occupation and participants are not expected to undertake any prison work during this time. 2.17 Within the community context of the RAPt unit all treatment

activities are structured by the 12 Step tradition. This model of recovery was established in 1935 with the genesis of Alcoholics Anonymous. It is based upon a fellowship of self-help. Although this has a spiritual ethos, it does not take a religious form. The RAPt programme is open to religious and n011-religious alike and participants are invited to develop their own interpretation of the references to 'Higher Power/God' in the language of the Steps. The 12 Steps programme aims to break down each individual's barriers of denial about their ability to control their use and to motivate them to examine and change their behaviour. It also tries to equip them with the skills and support networks offered in the fellowships of AA and NA, which are thought necessary to enable

22 Drug Treatment in Prison

the maintenance of a substance-free and offending-free lifestyle after release. 2.18 The primary programme now comprises the first five of the 12 Steps and is the foundation of the whole recovery programme. 4 Prisoners are expected to continue working through the remainder of the steps with the aid of a sponsor and fellowship support after their release. This is consistent with policy in similar residential treatment units in the community. Completion of each Step requires a prisoner to complete written assignments examining the aspects of their own history and behaviour relevant to the topic raised by the Step. Thus completion of Step 1 - 'We adntitted 'loe were powerless over our addiction (which may include alcohol, drugs, gambling, antisocial behaviour)-that our lives had become unntanageable'-requires participants to complete three assignments, examining the concepts of powerlessness, unmanageability, and their use of substances other than their drug of choice. Examination of powerlessness, for example, requires a participant to write down five specific examples (including dates, times etc.) of his or her own experience of the following circumstances: • loss of control due to addictive behaviour (blackouts, overdose, fits etc.) • destructive behaviour (violent outbursts, self-harm etc.) • accidents and/or dangerous situations (crashes, risky sex or drug use, passing out etc.) • attempts to control or stop using (detoxes, cutting down, moving home etc.) • substitution of other drugs or behaviours (changing method of substance use, compulsive eating/offending/sex etc.) • broken promises to family, friends, employers (to stop using, payoff debts, stop offending etc.). The other two assignments for Step 1 follow a similar pattern. Once completed, they are presented to their peer group, who with counselling staff may decide whether or not to accept the assignment as complete. All such assignments are undertaken in participants' free time, during the evenings and at weekends, and not during the working hours of the programme when group interaction is maximised. Literacy, whilst clearly an advantage, is

4

See Appendix III for a statement of the 12 Steps.

The RAPt Prograntnte

23

not a requirement as other members of the group or peer supporters may be approached to record dictated notes. 2.19 The content of the first five Steps provides both a structure for treatment and a link with the fellowships of NA and AA outside and, increasingly, inside prison. In addition, the progression of the Steps is intended to form a natural therapeutic path: Step 1 aims to break down prisoners' denial about their addiction: Steps 2 and 3 aim to motivate them towards identifying support to build a new

life; Steps 4 and 5 encourage them to examine the obstacles to recovery and the behaviours which have led to their failures in the past, to identify their strengths and assets on which they can build, and to create a realistic plan for the future. In all of these Steps, prisoners are reminded by contact with recovering addicts, both as counsellors and through fellowship meetings, that recovery is possible. 2.20 The formal elements of the assignments and Step work are supplemented by other processes, such as therapy groups, lectures, meditation, complementary therapies and sports activities. In some instances, individuals may also be given specific pieces of work to complete, such as anger or grief assignments, if their personal circumstances warrant it. Finally, a limited amount of work is done via one-ta-one counselling sessions, although the emphasis is primarily upon treatment in a group setting.

2.21 Compliance with the programme is monitored using a combination of feedback from prisoners and staff, through formal and informal community processes, and by regular random drug testing (currently never less than three tests every 14 days). Any significant infraction of the rules and expectations, or any relapse into substance use, will result in temporary or permanent exclusion from the programme. Two positive drugs tests will now result in exclusion from the programme for at least three months, although at the time of the research the period out of treatment tended to be left to the discretion of the staff team.

THE AFTER-CARE PACKAGE 2.22 RAPt has historically recognised the importance of supporting graduates in the continuation consolidation of their step-work, and in facilitating supportive contacts for them after release. The delivery of this service, however, has beel1 hampered by the availability of resources to direct into after-care and by the transfer

24

Drug Treatment in Prison

of graduates to prisons that do not have a RAPt programme. For the majority of the men who took part in the present study, after-care provision was extremely limited and ad hoc. Since this time the after-care package offered by RAPt has been significantly developed. 2.23 Most recently, the shape of the aftercare provision has substantially changed to take account of two factors. First, the requirements of the Prison Service's accreditation processs, together with a reexamination of the needs of RAPt clients, have led to the creation of a formalised series of 12 aftercare workshops. These are delivered either weekly or twice weekly and focus on skills training and relapse prevention. Second, the advent of the HM Prison Service CARATs initiative has meant that, in most prisons in which RAPt operates, the responsibility for overseeing the resettlement of RAPt graduates has passed from RAPt to the CARATs provider. The exceptions to this are Littlehey, where RAPt is the CARATs provider, and Downview, where RAPt continues to provide a full aftercare service to graduates of the programme who are to be released from those establishments. 2.24 Recent graduates are supported by the provision of regular groups that are usually run twice a week. Attendance at these is compulsory, as is their attendance at meetings run in the prison by outside fellowships such as AA or NA and their submission to regular drugs tests. In a limited number of cases, graduates may be offered individual sessions with their personal counsellor if that is deemed desirable and administratively possible. Otherwise, graduates are encouraged to acquire a sponsor through one of the fellowship organisations, who will act as a point of reference to assist with their continued step-work, establish contacts in the community and provide a positive role model of recovery. 2.25 Finally, information and practical advice is provided about aftercare arrangements in the community. Graduates are cautioned on the need to prepare themselves for their new way of life and advice is given on how they might circumvent some of the pitfalls. Residential secondary care facilities are described as useful interim measures, which provide a safe environment in which to continue recovery amongst other residents who will have undergone similar 5

Accreditation is the quality control mechanism employed by the Home Office in order to promote the effectiveness of programmes for offenders run in prisons or by the Probation Service. Those seeking to run such programmes must convince a panel of independent experts that the programme is likely to be effective in reducing reoffending and must also submit to an annual performance audit.

The RAPt Progranlnle

25

primary treatment, although not necessarily in a prison context. RAPt offers to provide a list of these facilities in appropriate areas and to assist in making necessary referrals. Similarly, information is provided about a range of drop-in counselling services and 12 Steps meetings in different areas of the country.

CHAPTER 3

The Original Sample BACKGROUND CHARACTERISTICS Criminal history 3.1 A total of 200 sentenced male prisoners were interviewed in the four prisons accommodating a RAPt treatment programme. Their ages ranged from 21 to 62, although most were in their twenties. Ethnic minorities made up just over a quarter (26 per cent) of the sample, most of whom were of African or African-Caribbean origin; proportions closely reflecting those of the national prison population. 3.2

The men that took part in this study comprised a relatively serious group of recidivist offenders with substantial prison experience. Their current sentences had been imposed for a wide range of offences, most typically burglary and drugs offences. Although fewer than one in three had received their present sentence for a violent offence, more than half the sample (59 per cent) had a previous conviction for an offence involving violence. Eight out of ten had served a previous prison sentence and, on average, had served four previous custodial terms. They had accumulated an average of 15 previous convictions and only seven of the 200 men interviewed had no prior criminal record. Half the men had at least one disciplinary offence listed against them during their present sentence.

3.3 There were, however, some significant differences between the criminal profiles of the graduates and those of the other men in the sample. Graduates were generally serving longer sentences: half the graduates were serving sentences of more than three years in comparison to one quarter of the non-graduates. Graduates were also more likely to have received their current sentence for robbery or for a drugs offence (see Table 3.1) and they were more likely to have previous convictions for drugs offences (see Table 3.2).

The Original Sample

27

Current offence Status

Robbery

Drugs

Other

Total

Graduates

24 (25%)

25 (26%)

46 (48%)

95

8 (8%)

13 (12%)

84 (80%)

105

32

38

130

200

Non-Graduate Total

Table 3.1: Status of original sample by current offence

Previous convictions include drugs Status

Yes

No

Total

Graduates

54 (57%)

41 (43%)

95

Non-Graduates

41 (40%)

62 (57%)

103

Total

95 (48%)

103 (520/0)

198*

*missing data

=2

Table 3.2: Status of original sample by previous conviction for drugs offence

3.4

Almost all the men felt that their drug use had played a significant part in their offending history and three quarters of them were convinced that this was the main cause of their offending. Primarily they claimed that acquisitive crime had funded their drug use, and only about a quarter of them thought that their offending had been precipitated by drug induced behaviour. Although most of the men said that they had committed criminal offences before their drug use became a problem, one in four claimed that they had not offended at all prior to this. Amongst those who had previously offended six out of ten held the firm belief that their offending behaviour had become either more frequent or more serious, or both, following the onset of drug misuse.

Drug using history 3.5 Substance misuse for the vast majority of the sample was longstanding. The average length of addiction amongst the graduates was 13 years, dropping to ten years for the non-graduates (see Table 3.3).

28

Drug Treatment in Prison

Length of addiction Status

< 1 year

1-5 yrs

6-10 yrs

11-20 yrs

20+ yrs

Total

Graduates

1(1 0/0)

14 (14 %)

29 (29%)

41 (41 %)

10 (10%)

100

Non-Graduates

2 (2%)

26 (270/0)

35 (37%)

32 (34%)

5 (5%)

95

3

40

64

73

15

195

Total

Table 3.3: Status of original sample by length of addiction

3.6

Although most of the sample could be classed as polydrug users the majority had a single drug of choice (see Table 3.4). Most commonly this was heroin (29 per cent), but one in five selected alcohol as their drug of choice and a similar proportion identified cocaine. Amongst the heroin and cocaine users most were not intravenous users but a quarter of them admitted that they had injected the drug at some time and most of these men had shared needles.

Drugs of choice

Number

Percent

Cannabis

11

5.5

Heroin

58

29

Cocaine

38

19

Amphetamines

2

1

Ecstasy

13

6.5

Alcohol

40

20

Polydrug

14

7

Drug and Alcohol

19

9.5

Other

4

2

Total*

199

* Missing Data for one man who cited gambling as addiction Table 3.4: Drugs of choice

The Original Sample

29

3.7 There were differences between the drug-using profiles of the

graduates and drop-outs in comparison with the non-starters. The former groups were significantly more likely than the latter to be heroin or cocaine users: 53 per cent of graduates and drop-outs were heroin or cocaine users in comparison with 39 per cent of nonstarters. I 3.8

There was virtually no dissent amongst the men that their drug use constituted a problem for them and the overwhelming majority (89

per cent) readily identified themselves as a ' drug addict' or as an 'alcoholic' or, in a quarter of the cases, as both an addict and an alcoholic. In the month prior to coming into prison almost everyone (93 per cent) had used their drug of choice and for the vast majority (84 per cent) this was on a daily basis. Unsurprisingly, there was widespread agreement that drug and/ or alcohol use had come to dominate their lives. 3.9

Half of the sample had previously succeeded in giving up their use of drugs and/ or alcohol. The vast majority of these men claimed that during this period they had experienced symptoms of withdrawal, mainly an overwhelming craving for their drug of choice. They had started using again for a variety of reasons largely to do with sub-cultural and lifestyle factors and because they missed the drug and wanted to return to its use. 'I've given up a few times.... I was just obsessed with it. All I wanted to do was be smashed': Graduate. Drug of choice alcohol. Length of use nine years. 'I've given up five times before. I don't know why I go back to it. If I knew that I wouldn't be sat here. I always crave it': Drop-out. Drug of choice heroin. Length of use 17 years. 'On release, as I left the gate my family was there with a can. That started me using again': Non-Starter. Drug of choice alcohol. Length of use two years. 'I tried to give up once after my first prison sentence and it lasted for about a year. But I lost my job and just became lazy and depressed and picked up-I was straight back in it': Graduate. Drug of choice cocaine. Length of use 14 years.

1

The reason for this is not entirely clear, but given that non-starters tended to be weighted towards those serving shorter sentences it may be that heroin and cocaine users were more likely to have a serious offence profile and longer sentences. Only one heroin user and none of the cocaine users had no previous convictions.

30

Drug Treatment in Prison

3.10 Most (60 per cent) of the men had no prior experience of a drug treatment programme. Of those who had embarked on previous treatments and were able to identify the type of treatment they had received, 24 said that they had participated in a 12 Step programme, 18 had methadone treatment and ten individual counselling. Although these various interventions had usually led to a period of recovery the effect was generally short-lived, lasting in the vast majority (82 per cent) of cases for less than six months. 3.11 The reasons the men offered for the failure of these earlier interventions could be divided into two categories. On the one hand were those who tended to blame themselves for their return to drug use, claiming that they lacked a personal commitment to change at that time. On the other, were those who explained their failure in terms of a conspiracy of circumstances, namely that their life situations had made it impossible for them to give up drugs, or that the treatment programme was inappropriate to their needs. 3.12 A little over a quarter of the sample had experienced treatment for a psychological or psychiatric disorder. This proportion is broadly consistent with documented findings for the general prison population. 2

DRUG USE IN PRISON 3.13 Three quarters of those who used drugs in prison said that they did so on a very regular basis: either every day or at least two to three times a week. Cannabis was the single most widely used substance but fewer than one in three of the men had restricted their use to cannabis. Heroin had been used in prison by about half of the men interviewed and a third (34 per cent) of the sample said that they had drunk alcohol in prison. 3.14 There were surprisingly few positive drug tests recorded against the total sample. Only about one in three of the men had returned a positive test during their present sentence and in over half these cases the test only revealed evidence of cannabis use. 3 Clearly the results of the testing procedures in the prisons covered by the present research severely underestimated the level of use admitted

2

3

Office for National Statistics (1998), Psychiatric Morbidity Al1lOngst Prisoners London, Stationery Office. 50 men said that they had used heroin during their present sentence either on a daily basis or at least two or three times a week. Only 13 men in the entire sample had returned a positive test for heroin.

The Original Sample 31

by the men in this sample. Furthermore, few men thought that the introduction of mandatory drug testing had affected their consumption of drugs in prison.

CHANGES IN DRUG USE POST-RAPt 3.15 Prior to enrolling with RAPt seven out of ten men had been using drugs during their present sentence. After enrolment this picture was reversed and the vast majority (80 per cent) said that they had abstained from all drug use since leaving the programme or preadmission group, with more than eight out of ten claiming to have been clean for longer than one month. 3.16 Amongst those who had moved on from the pre-admission group and had embarked upon the therapeutic programme, about one in five had failed to maintain total abstinence and had used drugs, usually heroin, during that time. In almost all of these cases their drug use had become known and they were required to accept a 'lie down' before rejoining the programme. 3.17 In terms of sustaining a drug-free lifestyle in prison it was evident that graduates of the programme were the most successful. Interestingly, the non-starters appeared to be more successful than the drop-outs, half of whom returned to drug use before being released (see Table 3.5). 3.18 Amongst the minority of persistent users almost half were solely using cannabis but a similar proportion were using heroin, either with or without cannabis.

Status

Used

Abstained

Total

Graduates

5 (5%)

88 (95%)

93

Drop-Outs

17 (49%)

18 (51 %)

35

Non-Starters

16 (24%)

51 (76%)

67

Total

38 (19%)

157 (81%)

195

Table 3.5 Status of original sample by substance-use in prison after contact with RAPt

32 Drug Treatnlent in Prison

CHANGES IN PRISON BEHAVIOUR POST-RAPt 3.19 Most inmates had applied for a place on a RAPt programme in order to get help to overcome their drug or alcohol problem. A small but significant minority had a different agenda, which included making a good impression on the Parole Board and facilitating a prison allocation closer to home. There were also a few others who were simply motivated by curiosity and had no commitment to drug therapy. 3.20 Irrespective of their motivation almost everyone who had embarked on the treatment programme, both graduates and drop-outs, felt that they had gained from the experience. Although two-thirds thought they had gained an ability to control their drug or alcohol problem, the men felt that, more than anything, they had achieved a sense of personal development that went beyond the limits of their dependence on drugs. This had consequences for their behaviour and attitudes inside prison which they argued were less stereotypically hostile to prison staff and more tolerant towards other prisoners. Graduates and drop-outs also felt more positive about their relationships with their families and claimed that their attitudes to offending, which had been largely driven by their drug dependence, had also changed for the better. 'RAPt has helped me in a different way. It's expanded my consciousness': Graduate 'It made me look at the risks I was taking and how insane my behaviour was. Also how other people were affected by my crimes':

Graduate 'It helped with my paranoia. I'm much less paranoid than I was': Graduate

3.21 In addition to the RAPt sessions most of the men attended meetings held in the evenings or at week-ends by outside volunteers from Alcoholics Anonymous or similar self-help organisations. The men appreciated the meetings for the support and reinforcement they provided by identifying shared experiences and presenting positive role models of recovery. Graduates were, however, more than twice as likely to attend these meetings than either the drop-outs or nonstarters. Nonetheless, some of the non-attenders anticipated going to meetings after their release, but again this commitment was most frequently expressed by the graduates.

The Original Sample 33

POST-RELEASE PLANS 3.22 A commitment to abstinence in relation to illicit drugs was expressed by about half the sample, although slightly fewer thought that they would refrain totally from alcohol. There were 100 men who were confident of their ability to avoid future drug or alcohol dependence and most of these men thought that this was due to their own commitment to change rather than the single impact of

the RAPt programme. 3.23 The men's expectations were, however, related to whether or not they were graduates of the programme. Graduates were almost twice as likely as non-graduates to say that they would not use illicit drugs (see Table 3.6).

Status

Don't know

Yes

No

Hope not

Total

Graduates

16 (170/0)

2 (20/0)

62 (65%)

15 (16%)

95

Drop-Outs

6 (17%)

10 (29%)

13 (37%)

6 (17%)

35

Non-Starters

5 (8%)

26 (390/0)

25 (38%)

10 (150/0)

66

100

31

196

Total

27

38

Table 3.6: Status of original sample by anticipate illicit drug use post-release

3.24 Amongst those who anticipated using illicit drugs, or who thought they might do so, about half were referring to the use of cannabis that was widely regarded as being non-harmful. 3.25 Attitudes towards social drinking were also ambivalent, particularly amongst those who had not previously experienced alcohol dependence. The graduates, however, were twice as likely as the non-graduates to say that they would abstain from drinking alcohol (see Table 3.7).

34

Drug Treatment in Prison

Don't know

Yes

No

Hope not

Total

Graduates

19 (20%)

8 (8%)

53 (56%)

15 (16%)

95

Drop-Outs

8 (23%)

11 (31 %)

11 (31°/0)

5 (14%)

35

Non-Starters

7 (100/0)

37 (53%)

18 (26°/0)

8 (11 %)

70

34

56

82

28

200

Status

Total

Table 3.7: Status of original sample by anticipate alcohol use post-release

3.26 Tables 3.6 and 3.7 show that although there was a general trend of

optimism, a significant number of men felt uncertain about their ability to avoid future dependence. The extent of this equivocation was found to be similar amongst graduates and non-graduates and appeared to be unaffected by their drug of choice.

CONCLUSIONS 3.27 The original prison sample comprised a relatively serious group of recidivist offenders with extensive prison experience. Only seven men had no previous convictions. The graduates of the RAPt programme, however, had the most entrenched criminal profile, in that they were serving longer sentences and were more likely to have a criminal history that included convictions for violence and drugs offences. Virtually everyone believed that their offending was drug-related and most of the men said that their drug use was the main cause of their offending behaviour. 3.28 Typically their history of substance misuse was longstanding: the

average period of addiction was 13 years for graduates and ten years for non-graduates. The majority of men in the sample were polydrug users but the most common drug of choice was heroin. The graduates and drop-outs were more likely than the non-starters to be heroin or cocaine users. For most of the men their contact with RAPt represented their first experience of drug rehabilitation. Those who had experienced previous treatments had usually enjoyed a short period of recovery but this had rarely exceeded six months. 3.29 Drug use in prison was widespread: regular use of cannabis and heroin was common. About a third of the sample said that they had drunk alcohol in prison. Few men felt that the introduction of

The Original Sample 35

mandatory drug testing had affected their consumption. There were surprisingly few positive tests recorded even for those men admitting daily use of heroin. 3.30 Contact with RAPt, whether as members of the pre-admission group

or as participants on the programme, was associated with a significant shift in the inmates' drug-using behaviour. A majority of the sample abstained from all drug use during their period of contact. Graduates, however, were more likely than either the dropouts or non-starters to be maintaining a drug-free lifestyle in prison. 3.31 Participation in the RAPt, programme was held by the men to be a positive experience that had assisted them to control their drug and/ or alcohol problem. However, the benefits of the programme extended beyond drug rehabilitation to encompass a broader sense of personal development and general attitudinal change that had consequences for their behaviour in prison. 3.32 Although the RAPt programme promotes total abstinence from all

drug and alcohol use, there was considerable equivocation amongst the sample about whether or not this was personally necessary or relevant. The graduates of the programme were significantly more likely than the non-graduates to subscribe to, and anticipate, a future drug-free lifestyle.

CHAPTER 4

Post-release Experience THE SUB-SAMPLE 4.1

A total of 75 men from the original prison sample were successfully contacted and re-interviewed following their release from prison. The composition of this sub-sample varied only slightly from the original prison sample in that it contained a marginally higher proportion of graduates and a lower proportion of non-starters. Nonetheless, there was a fairly even division between graduates and non-graduates in both samples (see Table 4.1).

Status

Original prison sample

Sub-sample

Graduates

95 (47.50/0)

42 (560/0)

Drop-Guts

35 (17.5 %)

13 (17%)

Non-Starter

70 (350/0)

20 (27%)

200

75

Total

Table 4.1: Status of original prison sample and sub-sample

4.2

In respect of their criminal histories there were no significant differences between the two groups in relation to their original offence and length of sentence, the number of previous convictions and the number of previous custodial sentences. The sub-sample was also virtually identical to the original sample in relation to their drugs of choice and lengths of addiction. Demographic variables of age and race were also comparable. 1

4.3

Although it was intended that the men would be re-interviewed six months after their release from prison the difficulties of establishing contact resulted in these post-release periods varying for different respondents. Two thirds of the men were interviewed between six and nine months after release but more than one in five were

1 See Appendix I for comparative data on original sample and sub-sample.

Post-release Experience 37

tracked down between ten and 19 months after leaving prison. The 2 mean time since release was eight months. 4.3

An important element in the resettlement of any prisoner is the extent to which he or she is integrated into an environment that provides stable material conditions and a network of interpersonal support. In this research the post-release experience of the men was examined in relation to their accommodation, employment and social contacts.

ACCOMMODATION 4.4

On release from prison half the men went to live in accommodation they described as their own home or the home of a relative. In most cases the men returned to the accommodation they had lived in prior to their sentence or found accommodation in the same area. The vast majority of men made these arrangements for themselves, sometimes with the help of family and friends. Only 24 men, about a third of the sample, went to live in a new location on release. In 13 of these cases this was due to their admission to a residential secondary care programme, mostly facilitated through RAPt.

4.5

RAPt provides after-care to its graduates by offering them continued help and support for their drug rehabilitation. This can take different forms, from arranging contact with a sponsor and introductions to local 12 Step meetings through to residential placements in full-time secondary care. In this respect the postrelease experience of the graduates differed from the rest of the sample in that, on leaving prison, they had more professional assistance and were significantly more likely to be admitted into a residential drug treatment programme. The 13 men accommodated in secondary care were all graduates. When this group is excluded, however, graduates were just as likely as the non-graduates to return to their previous homes and home areas.

4.6

By the time the men were interviewed fewer than half (43 per cent) were still living at the same address. Amongst those who had relocated about half had made what they regarded as a progressive move. Most of the others, however, had moved on because they had returned to prison. A total of 20 men had returned to prison by the time they were re-interviewed.

2

There were ten men, five graduates and five non-graduates, who had been released for slightly less than six months.

38 Drug Treatnlent in Prison

4.7

Leaving aside the imprisoned group, only about half the men regarded their present living arrangements as permanent; those who anticipated moving were mainly those who were still aspiring to gain their own rented accommodation. In terms of the social environment of their accommodation only one in five of the men was living alone, most of the rest were living in a family context,' either with a partner, with or without children, or with their parents or another relative.

4.8 There were no significant differences between the graduates, dropouts and non-starters in relation to the type of their accommodation

or in the social configuration of their households.

EMPLOYMENT 4.9 Excluding the men who had returned to prison, half the sub-sample was in current employment or education at the time of their interview, although only half of these had full-time, permanent jobs (see Table 4.2). One in three men had been permanently unemployed since their release. Most commonly the men who were in work had found their job through the assistance of a relative or a friend. At the time of the interview about half of the sample were living primarily on state benefits. 4.10 At the time of the interview graduates were significantly more likely than non-graduates to be in current employment. Permanent fulltime jobs were, however, a rarer commodity and the difference between graduates and non-graduates was not statistically significant. It is possible, however, that one of the consequences of going into secondary care is to delay an individual's entry or return to permanent employment. 4.11 Amongst those who were currently unemployed, there were no significant differences between graduates and non-graduates in relation to the likelihood of them having not worked at all since their release. Graduates were also just as likely to be living on state benefits.

Post-release Experience 39

Current employment

Graduates

Non-graduates

Employed full or part-time

15 (36%)

7 (21%)

Education Course

5 (12%)

1 (30/0)

Unemployed

11 (26%)

13 (39%)

2 (5%)

1 (30/0)

9 (210/0)

11 (330/0)

42

33

Rehabilitation/Secondary

Care Imprisoned Total

Table 4.2 Status of sub-sample by current employment

INTERPERSONAL SUPPORT 4.12 Inevitably it was easier to find men with established ties in the

community than those who had a more rootless lifestyle. Partly as a consequence of this the majority of the sample, including those who had returned to prison, had regular contact with their parents or other members of their family of origin. Only six men, three graduates and three non-graduates, had no contact at all. 4.13 Two thirds of the men regarded their family as a source of help and support in relation to their drug problem. Nonetheless, almost half of the men who were in touch with their families had contact with

at least one member who had a serious drug or alcohol problem and in two thirds of these cases they shared the same problem substance. 4.14 Amongst the men who were in touch with family members with a

drug or alcohol problem, opinion was evenly divided between those who viewed this contact as a problem and those who did not. Only half the men who viewed it as problematic had been able to devise a strategy to protect themselves or to cope with the situation. There were no differences between graduates, drop-outs and nonstarters in any of these respects concerning their family contacts. 4.15 Half the men who were interviewed had a wife or partner with whom they had regular contact and, again, over half viewed this relationship as a source of help and support with their drug

40

Drug Treatnlent in Prison

problem. In the vast majority of cases their partners were said to be free of any problem with drugs or alcohol. 4.16 Fewer than one in five men said that their partner misused drugs or alcohol but, when they did, it was usually the same problem substance as their own. Those facing this situation were evenly divided over whether this caused them any difficulties but, amongst those who were concerned, no one had devised a strategy for coping with it. Again the pattern of responses was the same for graduates, drop-outs and non-starters. 4.17 Excluding those who had returned to prison, Olle in three men were living with others who had a drug or alcohol problem, and in the majority of cases the substance of choice was identical to his own. Only half of them, however, regarded this as problematic for their own recovery. 4.18 The vast majority of the men had resumed old friendships on release from prison and in nine out of ten cases these social contacts misused drugs and/ or alcohol. Half the men had made new friends and although the incidence of substance misuse was less frequent it was still prevalent: two thirds of the men who had made new friends said that these included people who had a significant problem with drugs and/ or alcohol. 4.19 Graduates were, however, significantly more likely than nongraduates to have made new friends with people who did not suffer a drug or alcohol problem.

CONCLUSION 4.20 The sub-sample of inmates who were contacted after their release

from prison were men who typically had a network of interpersonal supports, provided primarily by their family of origin but also by their wives or partners. Almost all of them had a circle of friends or social contacts, mainly people they had known prior to their last sentence. Most strikingly the social world in which these men existed exposed them to regular contact with people who misused drugs and/ or alcohol. The over-representation of men with family supports is likely to be due to the method of contacting men after their release from prison. Inevitably it was easier to find men with established ties in the community than those who had a more rootless lifestyle. 4.21 Materially their conditions were less favourable, with a quarter of the sample having returned to prison by the time of the interview.

Post-release Experience 41

Amongst the rest, only half of the men were living in accommodation that they regarded as permanent and even fewer were in permanent full-time employment. 4.22 The social circumstances discussed here varied little between the graduate population and the drop-outs and non-starters. However, the graduates were more likely to have received the formal support of residential treatment following their release and, by the time they were interviewed, they were better placed in relation to employment. The graduates had also been more successful in establishing new social contacts that were free of drug or alcohol problems.

CHAPTERS

Drug Use Post-release 5.1

The primary objective of the RAPt programme is to enable participants to lead a drug and alcohol-free lifestyle. It is aimed typically at individuals with a long history of substance misuse and, in common with most treatment programmes, it requires abstention from drugs and alcohol during treatment. However, it also aims to persuade participants that it is in their long-term interests to continue that abstinence after the end of treatment.

5.2

This chapter describes how the men in the sub-sample fared in relation to drug use after their release from prison. It examines how far they had successfully lived up to the abstinence model, but it also explores the extent to which other changes in the frequency and nature of their drug use are evident.

5.3

The picture that emerges is complex and reveals varying levels or tiers of recovery rather than a strict binary division between recovery and relapse. The analysis focuses on the following questions:

.

• whether the men used any substances after release • whether they abstained from their drug of choice but used other substances • whether their drug use persisted and whether this was to the same degree as before; and • whether those who relapsed were able to re-establish recovery. 5.4

When the original sample of 200 men was interviewed in prison they reported a significant reduction in illicit drug use following their contact with RAPt. Two-thirds of the men said that they had abstained from using all drugs since enrolling on the pre-adlnission group or joining the programme. They recognised, however, that the major test would come after their release, when the controls and supports within the prison environment would no longer be present. The sub-sample that was followed-up after release confirmed the validity of this expectation.

Drug Use Post-release 43

THE FIRST TIER OF RECOVERY-ABSTINENCE l

5.5

Two-thirds of the 75 men followed-up in the community said that they had successfully avoided all drug use for the remainder of their prison sentence. After their release, however, 58 respondents, 77 per cent of the sub-sample, admitted that they had relapsed.

5.6

Arguably, the most successful category of respondents comprised those who had managed to avoid all substance use post-release. Those who abstained from all drug and alcohol use may therefore be conceived as occupying the First Tier of Recovery. There were 17 men who claimed to fall within this category. Twelve had been out for six months or longer, the mean time post-release being seven months. 2 All but one of these candidates were graduates, the exception being a drop-out (see Table 5.1).

Used any substance post-release Status

Yes

No

Total

Graduates

26 (620/0)

16 (38%)

42

Drop-Outs

12 (920/0)

1 (8%)

13

20 (1000/0)

0

20

58 (77%)

17 (23%)

75

Non-Starters Total

Table 5.1: Status of sub-sample by use of any substances post-release

5.7

t

2

Respondents were asked to submit to a drug test if they claimed to have abstained from using their drug of choice since release from prison. Drug tests were therefore conducted on all 17 men who claimed total abstinence. These revealed 15 negative results: 14 graduates and one drop-out. The positive test results related to two graduates who had used cocaine, which in both cases was their drug of choice. The tests, therefore, verified the self-reported claims in almost nine out of ten cases.

See Chapter 1, paras. 1.10-1.13 and 1.18-1.21, for description of selection of subsample. See Appendix Il, Table 1 for post-release periods for sub-sample.

44

5.8

Drug Treatment in Prison

It would seem that although a minority of the sub-sample occupied the first tier of recovery, graduates of the programme were significantly more likely than non-graduates to fall within this category of success. Fourteen graduates, one in three of all graduates followed-up post-release, had abstained from all drug and alcohol use. This compared with only one drop-out, approximately three per cent of the non-graduate sub-sample (see Table 5.5 below). It is perhaps worthy of note that this drop-out had spent a full two months on the programme and felt that the RAPt course had played a central role in facilitating his recovery.

SECOND TIER OF RECOVERY-ABSTAINING FROM DRUGS OF CHOICE 5.9

A second tier of recovery accommodates those men who had succeeded in abstaining from their drugs of choice even though they had used other substances. Whether the men returned to their drugs of choice is an important question given that these were the substances they had identified as being problematic for them and as being the primary targets for treatment.

5.10 There were 17 men who said that although they had used other substances since their release they had abstained from tlleir drug of choice. These men tended to have been released for longer than those in the first tier of recovery. Fourteen of them had been released for six months or longer and the mean period post-release was nine months. 3 5.11 It can be seen that, in total, there were 34 men in the sub-sample who claimed that they had not used their drug of choice since their release from prison. This group included the 17 men in the first tier of recovery who said that they had abstained from all drug and alcohol use and the 17 who claimed to have abstained only from their drug of choice. 5.12 On the basis of the self-report data, gradllates of the RAPt programme appear to be significantly less likely to have reverted to their drug of choice after release. Almost six out of ten graduates claimed this level of recovery in comparison with three out of ten non-graduates (see Table 5.2). 5.13 This difference, however, is due to the greater likelihood of graduates abstaining from all substances and therefore dominating 3 See

Appendix Il, Table 1.

Drug Use Post-release 45

the first tier of recovery. The 17 men in the second tier of recovery were just as likely to be non-graduates as graduates (see Table 5.3).

Used drug of choice

Not used drug of choice

Total

Graduates

18 (430/0)

24 (57%)

42

Non-Graduates

23 (700/0)

10 (30%)

33

Total

41 (560/0)

34 (44%)

75

Status

Table 5.2: Status of sub-sample by whether used drug of choice post-release

Status of substance users postrelease

Used drug of choice

Not used drug of choice

Total

Graduates

18 (69%)

8 (31 %)

26

Non-Graduates

23 (72%)

9 (28%)

32

41

17

58

Total

Table 5.3: Status of sub-sample users by whether used drug of choice postrelease

5.14 The men's attitudes to the use of 'other drugs' revealed a discerning approach to different substances and a considerable degree of equivocation about the need to abstain from all drugs. In particular, it was suggested that alcohol and cannabis were not universally harmful substances and that their use did not necessarily undermine a person's recovery. 5.15 Most of the 17 men who had abstained from their drug of choice but who had used 'other drugs' since their release from prison had restricted their use to either cannabis or alcohol or both (see Table 5.4). Again, there were no significant differences between the graduates and non-graduates in this respect. However, the tendency for graduates to limit 'other drug' use to alcohol and to avoid illicit substances would merit further examination on a larger sample.

46

Drug Treatment in Prison

5.16 Drug tests were conducted in nine of the 17 cases of second tier recovery and six negative results were confirmed (see Table 5.5).4 Again there were no differences between graduates and nongraduates.

Graduates

Non-graduates

Total

Use alcohol only

4

2

6

Use cannabis only

1

3

4

Use alcohol cannabis

1

2

3

6

7

13

Use other drugs

2

2

4

Sub-total

8

9

17

Use other drugs and drug of choice

13

15

28

Total

21

24

45

and

Sub-total Limit use to alcohol and/or cannabis

Limit use to 'other drugs'

Table 5.4: Status of sub-sample by pattern of 'other drug' use.

4

The reasons for not administering tests to the remaining eight men were as follows: one refused, six had returned to prison and for one man a drug test was not appropriate as his addiction related to compulsive gambling. It was not possible for the fieldworker to administer drug tests to men in prison.

Drug Use Post-release 47 Graduates

Drop-outs

Non-starters

Total

Positive

2

0

0

2

Negative

14

1

0

15

Sub-total

16

1

0

17

Positive

2

0

1

3

Negative

3

1

2

6

Sub-total

5

1

3

9

Total

21

2

3

26

Test result Tier 1

Test result Tier 2

Table 5:5 Status of sub-sample by drug test results

5.17 It can be concluded that a total of 34 men claimed to have reached at least the second tier of recovery: namely that they had abstained from using their drug of choice since being released from prison. Drug tests were conducted in 26 of these cases, confirming the selfreported claims of 17 graduates and four non-graduates (See Table 5.5). This indicated that the self-reported data on recovery was accurate in about 80 per cent of cases. s

5.18 The tests confirmed that 17 graduates, 40 per cent of all graduates followed up after their release, had achieved at least the second tier of recovery, in comparison with only three non-graduates, 12 per cent of all non-graduates in the sub-sample.

THE INFLUENCE OF DRUGS OF CHOICE ON RECOVERY 5.19 The specific drug of choice was also an important factor in affecting

whether or not the men returned to its use. Those who identified alcohol as their drug of choice were significantly more likely than 5

See Appendix Il, Table 2 for details of types of drug tests administered and results.

48 Drug Treatment in Prison

other users to have returned to its use. Eight out of ten alcoholics in the sub-sample had relapsed since their release, in comparison with less than half (45 per cent) of the other users (see Table 5.6). The legality and widespread availability of alcohol undoubtedly plays a critical role in shaping the post-release experience of the alcoholic group. Whilst it may be argued that many illicit drug users are likely to return to environments where the availability of their drugs of choice are equally abundant, the opportunities for avoidance are heavily weighted against the alcoholic group making them acutely vulnerable to relapse.

POST-RELEASE SUPPORT 5.20 Published research supports the common sense assumption that participation in after-care programmes increases the likelihood of rehabilitative success. 6 The experience of the sub-sample in this research confirmed the importance of secondary care in the community and post-release contact with self-help organisations.

Used drug of choice since release Drug of choice

Yes

No

Total

Cannabis

1 (100%)

0

1

Heroin

9 (43%)

12 (570/0)

21

Heroin and Cocaine

5 (54%)

6 (55%)

11

Cocaine

5 (330/0)

10 (67%)

15

Polydrug

4 (1000/0)

0

4

Alcohol

11 (790/0)

3 (21 %)

14

Drug and Alcohol

5 (83%)

1 (17%)

6

Gambling

0

1 (100%)

1

Missing Data

1

1

2

Total

41

34

75

Table 5.6 : Drugs of choice used post-release

6

Hiller M. L, Knight K. and Simpson D. D. (1999), 'Prison-Based Substance Abuse Treatment, Residential After-Care and Recidivism', Addiction 94(6) 833-42.

Drug Use Post-release 49

5.21 There were 13 men who, following their release from prison, went into residential secondary care. In the majority of cases this had been arranged for them by RAPt and all the men were graduates of the programme. Almost half of this group, six of the 13 men who had experience of secondary care, claimed to have achieved a first tier recovery. In other words, they claimed to have abstained from all drug and alcohol use since their release and, in every case, this was confirmed by a negative test result. It is therefore evident that, of the 14 graduates whose claim to a first tier recovery had been verified by test results (see para. 5.7 above), six of them went into residential secondary care after their release.

5.22 In addition to those in the first tier of recovery, there were two men who had experienced secondary care who claimed a second tier recovery by abstaining from their drugs of choice. Of these, only one was tested and this confirmed a negative result for heroin and cocaine, his drugs of choice. The other man had returned to prison and was not tested. 5.23 Contact with RAPt staff, other. former RAPt inmates and with self-

help organisations, such as Alcoholics Anonymous and Narcotics Anonymous, was also associated with a greater likelihood of recovery. Eight out of ten men in the first tier of recovery had made this type of contact post-release, including all of the 14 graduates who had returned a negative test result. This compares with about half of those in the second tier of recovery and about a third of those who had relapsed and used their drug of choice. 5.24 The men themselves offered various explanations for returning to their drugs of choice. These explanations tended to differ according to whether or not the men had experience of the therapeutic programme. In other words, the explanations put forward by the graduates and drop-outs tended to focus on different issues from those offered by the non-starters. 5.25 Most typically, the men described a process of drifting back to their drugs of choice propelled, in the case of non-starters, by a desire to re-experience the physical pleasures they associated with the drug. This sense of nostalgia was expressed far less frequently amongst the graduates and drop-outs. Only one in four of these men offered this as an explanation compared with more than eight out of ten non-starters. 'I was fed up with drinking coke-and it was Christmas!': Non-Starter.

Drug of choice-alcohol. At time of interview still drinking alcohol.

50

Drug Treatment in Prison 'On release, obviously 1 had a drink in celebration': Non-Starter. Drug of choice-alcohol. Relapsed on day of release. At time of intervie'lv still drinking alcohol.

5.26 The graduates and drop-outs were more likely to explain their relapse in terms of a personal crisis or blame the erosive effects of a drug-using environment. 'I was working with a bunch of lads and hadn't been to a meeting and went to the pub on a Friday after work. I started on coke [cola] and ended up on beer. After that I was on a binge for four days':

Graduate. Drug of choice-alcohol. Relapsed three lveeks after release. At time of interview had not used any substances for 12 1110nths. 'Bumping into old shit people it just got the better of me': Graduate.

Drug of choice-heroin. Relapsed one month post-release llsing crack. At tinle of intervieu) llsing methadone. 'Cannabis is a normal way of life for me. But I suppose I got back into cocaine because of the friends I mixed with and the problems I had then': Graduate. Drugs of choice-poly-drug use. Relapsed shortly after

release. Poly-drug use at time of interview.

5.27 Almost all the graduates of the programme, as well as some of the drop-outs, expressed a high degree of motivation to break with their drug-using lifestyles. In many instances, however, these aspirations were swamped by counter imperatives. Most of the men lived in geographical locations, and interacted in social worlds, where drug-taking was commonplace. Moving out of these environments and re-establishing a life elsewhere was rarely a viable option for men who had scant financial resources and who llad little or no experience of this type of personal mobility. Even for those who had relocated, the material and emotional resources required to overcome the consequent isolation and loneliness, and to turn a ~fresh start' into a new and different lifestyle, were often lacking. 'They found me a bedsit. After six days I'd had enough and I went back to London. [My using] had a lot to do with the area I was living in-but then, Brixton is my home ... I used for the first time after three days. Then a week. I've relapsed four or five times. Each time I relapse it's for a longer time and it's harder to pull myself out': Graduate. Drugs of choice heroin and crack. Addicted 13 years. Still using.

5.28 It was clear that, for a large number of men, the use of their drug of choice had provided them with positive experiences that they

Drug Use Post-release 51

missed. Virtually all of them recognised that the costs of their addictions logically outweighed any calculable benefits, but the environments into which they were released did not readily yield immediate compensations for this sense of loss. 'Basically, I was working all night, coming back and going to bed then waking up in the afternoon feeling really depressed': Graduate. Drug of

choice heroin. Relapsed three months after release. At ti111e of interview llsing heroin. 'It was a crazy decision really. But it was my birthday. If life was going good I wouldn't have needed it. I don't use it that much. It's only in times of stress': Non-Starter. Drug of choice-cannabis. At tinle of

interview still using cannabis.

RECOVERY FROM RELAPSE 5.29 So far in this chapter the effectiveness of the RAPt programme has been discussed solely in terms of whether the men have, or have not, used drugs or alcohol post-release. Another way of assessing their recovery is to take a more dynamic perspective and examine the persistence of their drug use post-release. In acknowledging that the process of recovery from addiction is frequently characterized by relapse, the relevant questions move on from whether or not drug use occurred to whether or not those who did relapse were able to retrieve the situation and re-establish recovery. Re-establishing total abstinence-claims to first tier recovery 5.30 There were 38 men who, at the time of being interviewed, said that they were not using any substances. This group comprised the 17 respondents who had claimed total abstinence since their release, together with a further 21 men who admitted an early relapse but who claimed to be currently drug free (see Table 5.7).

52

Drug Treatment in Prison

Current use of 'other drugs'

Current use of drug of choice

Total

Yes

No

Yes

21

15

36 (28%)

No

0

38

53 (72%)

Missing data

-

-

1

21 (270/0)

53 (730/0)

75

Total

Table 5.7: All Current Drug Use 5.31 Overall, more graduates than non-graduates managed to recover

from a relapse and to re-establish a drug-free lifestyle. Amongst the 26 graduates who relapsed post-release eleven (42 per cent) said that currently they were not using any substances in comparison to 32 per cent of non-graduates (see Table 5.8). This difference, however, did not reach statistical significance.

Current abstinence all substances

Current use

Missing data

Total

Graduates

11(42%)

15

0

26

Non-graduates

10 (32%)

21

1

32

Total

21 (360/0)

36

1

58

Status of relapsed population

Table 5.8: Status of relapsed sub-sample by current abstinence 5.32 In relation to the total sub-sample, half the men, at the time of being

interviewed, claimed that they were currently abstaining from all substances (see Table 5.9). Graduates were twice as likely as nongraduates to make this claim: almost two-thirds of the graduates in comparison with one in three non-graduates, maintained that currently they were not using any substances (see Table 5.9). T11is difference was, however, largely due to the predominance of graduates who had abstained from all substances since their release, rather than those who had recovered after a relapse.

Drug Use Post-release 53

Graduates

Non-graduates

Total

Abstinence Since Release

16

1

17

Current Abstinence

11

10

21

27 (64%)

11 (330/0)

38 (510/0)

Current Use

15

21

36

Missing data

0

1

1

Total

42

33

75

Drug use

Sub-total

Table 5.9 Status of sub-sample by current use of any substances

5.33 Drug tests were conducted on 19 of the 27 graduates who claimed current abstinence from all substances. These confirmed the selfreported data in over 89 per cent of cases. If the self-reported data is accepted to be at least 80 per cent accurate it can be estimated that just over half (52 per cent) the graduates followed up after release could lay claim to a current first tier recovery. In the majority of these cases (81 per cent) the men claimed that their period of recovery was six months or longer. Re-establishing abstinence from drug of choice-Claims to second tier recovery

5.34 It was stated earlier that there were 17 men who said that, since their release from prison, they had abstained from using their drugs of choice but had used other substances (see para. 5.10 and Table 5.3). In most cases this had amounted to drinking alcohol and/ or smoking cannabis. By the time they were interviewed, however, seven of these men claimed that they had moved on and were no longer using any substances. In other words, four out of ten of those who had reached the second tier of recovery improved on this position. There were, however, no significant differences between the graduates and non-graduates in relation to the likelihood of them progressing their recovery in this way. 5.35 The remaining ten men in the second tier of recovery were joined by five newcomers. These were men who had relapsed by using their drugs of choice after release but who claimed to be currently no

54

Drug Treatment il1 Prison

longer doing so, although still using 'other substances'. Again, graduates and non-graduates appeared equally likely to follow this path of recovery.

PERSISTENT USE 5.36 It was shown that a little over half the sub-sample, a total of 41 men, had used their drug of choice post-release (see Table 5.1). Despite this relatively widespread return to their drug of choice, it did not signal a wholesale reversion to the regular and frequent use that had characterized the men's lifestyles prior to their last sentence. At the time of their follow-up interview 21 of the 41 men who said that they had used their drug of choice admitted that they were still doing so. Amongst those who relapsed by using their drug of choice there appeared to be no significant difference between graduates and non-graduates in the likelihood of their persistence (see Table 5.10).

Status of those who had used drug of choice

Current use of drug of choice

Total

Yes

No

Graduates

9

9

18

Non-graduates

12

11

23

Total

21

20

41

Table 5.10 Status of sub-sample who used drug of choice by current use of drug of choice

5.37 Amongst the 21 men who had continued using their drugs of choice there was an indication that their level of use had declined. Prior to their last sentence eight out of ten were using on a daily basis, whereas after release only half of them continued to use at this level (see Table 5.11). Graduates and non-graduates were equally likely to reduce their level of use.

Drug Use Post-release 55

Daily use

2-3 times

Total

per week Level of use in 30 days prior to

last sentence Level of use in 30 days prior to

interview postrelease

17

4

(81%)

(19%)

10

11

(48%)

(53%)

21

21

Table 5.11: Frequency of persistent use of drug of choice

5.38 Hedonistic attractions continued to exert an influence over the persistent users. Half of this group said that they did not want to give up their drug of choice because they enjoyed using it and because it did not constitute a problem for them. The strength of this latter conviction was, however, somewhat mitigated by the fact that most of these men said that they would like to reduce their level of use. The nine graduates who were currently using their drug of choice were, however, significantly less likely than the others to believe that their use was under control. Only one graduate thought his drug use was under control in comparison with nine of the 12 non-graduate users.

CONCLUSIONS 5.39 The original sample of 200 men interviewed in prison reported a

significant reduction in illicit drug use following their contact with RAPt. Two-thirds of the men said that they had abstained from using all drugs since enrolling on the pre-admission group or joining the programme. 5.40 These results were mirrored amongst the 75 men in the sub-sample, amongst whom two-thirds said that they had successfully avoided all drug use for the rest of their time in prison.

56

Drug Treatment in Prison

5.41 The findings from this study suggest that when assessing the effectiveness of drug treatment programmes it might be more appropriate to conceive of drug rehabilitation in terms of degrees or tiers of recovery, rather than as a binary concept of adherence or non-adherence to total abstinence. By approaching it in this way the evaluation is able to take account of, not only abstinence from all substances, but abstinence from drugs of choice and recovery after a period of relapse. 5.41 The First Tier of Recovery represents abstention from all drug and alcohol use post-release. Seventeen men in the sub-sample stated they had achieved this level of success and all but one of them was a graduate. The exception was a drop-out but he had spent a full two months on the programme and was convinced that the RAPt course had played a central role in facilitating his recovery. 5.42 The Second Tier of Recovery comprises those who had abstained from using their drug of choice since release but who stopped short of total abstinence. There were 17 men who laid claim to this level of recovery. These respondents adopted a discerning approach to the use of different substances, particularly to the use of cannabis and alcohol. They argued that these were not universally harmful substances and their use did not necessarily undermine a person's recovery. The men who achieved the second tier of recovery were just as likely to be non-graduates as graduates. 5.43 All those claiming first or second tier recovery were asked to submit to a drug test. These confirmed self-reported claims in about 80 per cent of the cases. Most notably, they confirmed that 40 per cent of all graduates followed up after their release had achieved at least the second tier of recovery, in comparison with only 12 per cent of all non-graduates in the sub-sample.

5.44 Alcoholics were significantly more likely than any other substance users to return to their drug of choice after their release from prison. Eight out of ten alcoholics in the sub-sample had relapsed since their release, in comparison with less than half of the other users. The legality, relatively low cost and consequent availability of alcohol clearly places the alcoholic group in a uniquely vulnerable position. 5.45 North American research demonstrating the significant impact that after-care programmes can have in enhancing the prospects of recovery was underlined by the present study. Although at the time the research was conducted the RAPt programme did not have a formal after-care component linked to the prison-based programme,

Drug Use Post-release 57

there were 13 men, all graduates, who were found places in residential secondary care post-release. Almost half of this group claimed to have achieved a first tier recovery. But less rigorous support systems, such as contact with RAPt staff, other former RAPt inmates and with self-help organisations, such as Alcoholics Anonymous and Narcotics Anonymous, were also associated with a greater likelihood of recovery. Eight out of ten men in the first tier of recovery, and about half of those in the second tier of recovery, had made this type of contact post-release. 5.46 It has been suggested that the assessment of rehabilitative success should take account of recovery that is achieved after a period of relapse. Most inmates in the sub-sample had used their drug of choice after they were released from prison. Half of these men, however, claimed that they had subsequently re-established recovery at either a first or second tier level. Overall, more graduates than non-graduates managed to recover from a relapse and to re-establish a drug-free lifestyle, but the difference did not reach statistical significance. Nonetheless, it is estimated that at the time of their interview just over half the graduates were currently maintaining a drug-free lifestyle and for the majority of these men their period of first tier recovery had lasted for six months or longer. The fact that recovery is frequently a broken and fragmented process suggests that an important element in the development of after-care programmes should be the recognition and interruption of the cyclical pattern of relapse that characterizes the drug-using careers of many addicts. 5.47 A more modest degree of rehabilitative success might be claimed for those who had continued to use their drug of choice but who had reduced their level of consumption. In the sub-sample were 21 men who admitted that they were continuing to use their drug of choice. Yet amongst this group there was an indication that their level of use had declined. The numbers of men using on a daily basis had almost halved. There appeared to be no significant difference between graduates and non-graduates in this respect. 5.48 The nine graduates who were currently using their drugs of choice were, however, significantly less likely than the others to believe that their use was under control; only one graduate claimed to be in control of his drug use in comparison with three-quarters of the non-graduate users.

CHAPTER 6

Criminal Behaviour 6.1

Whilst the primary objective of the RAPt programme is to enable its participants to lead a drug and alcohol-free lifestyle, RAPt also attempts to encourage those who attend its courses to address their offending behaviour. The overwhelming majority of the original sample linked their drug or alcohol use to their criminal lifestyles in some way, and eight out of ten expressed the view that their substance misuse was the main cause of their offending. The purpose of this chapter is to consider first, whether there is any evidence that graduates of the RAPt programme have lower rates of reconviction; and secondly, whether those who have modified their drug use, by abstaining either from all drugs or solely from their drugs of choice, have reduced their level of offending. The chapter documents evidence of the post-release convictions of the 200 men in the original sample, based upon data from the Home Office Offenders' Index. It also looks in more depth at the nature and extent of the subsequent criminal behaviour of the sub-sample of 75 men followed-up after release.

6.2

The interactive relationship between drugs and crime is widely recognised and documented: Research has indicated, for example, that high rates of criminality are associated with periods of active use and lower rates with periods of non-use. 2 Other studies have demonstrated a correlation between the amount of drugs used and the amount of crime committed. 3 It should be noted, however, that most of this work has focused on heroin or cocaine users and that it is overwhelmingly concentrated on the behaviour of men rather than women.

1

2

3

Hough, M. (1996), Probletn Drug Use and Criminal Justice: A Review of the Literature, Drug Prevention Initiative Paper No 15, London: Home Office Central Drugs Prevention Unit; Edmunds, M., Hough M., Tumbull P. and May T. (1999), Doing Justice to Treattnent: Referring Offenders to Drug Services, London: Drugs Prevention Advisory Service. Ball J. C., Shaffer J. W. and Nurco, 0 N. (1983), 'Day-ta-Day Criminality of Heroin Addicts in Baltimore: A study in the continuity of offense rates', Drug and Alcohol Dependence, 12: 119-142 Johnson B. D., Goldstein E., Preble E., Schmeidler 0.5., Lipton 0.5, Spunt B and Miller T. (1985), Taking Care of Business: The Economics of Crime by Heroin Users, Lexington, MA: Lexington Books.

Crinlinal Behaviour 59 6.3

The nature of the linkage between drug misuse and criminality varies. It ranges from drug-related crime such as possession and supply to provide for the user's own habit, to other serious crimes, such as robbery and burglary, to obtain money to purchase drugs. Substance misuse can also impact in other ways, by reducing inhibitions or precipitating the use of violence, particularly when alcohol is involved. The overall findings from extensive American research suggest that the use of illicit drugs does not necessarily initiate criminal careers but it does intensify and perpetuate criminal activity: Street drugs seem to lock users into patterns of criminality that are more acute, dynamic, unremitting, and enduring than those of other offenders. 4

RECONVICTIONS-THE ORIGINAL SAMPLE 6.4

The names and dates of birth of the 200 men in the original sample were checked against the Offenders' Index compiled by the Home Office. This listed any convictions the men had acquired between their date of release and 30 June 1999. Valid data was available for 188 cases. 5 The men had been released from their original sentence for varying lengths of time but the mean time post-release was 13 months (see Table 6.1).

Post-release period

Graduates

Non-graduates

Total

Less than six months

11 (13%)

12 (12%)

23 (12%)

6-11 months

29 (33%)

25 (25%)

54 (29%)

12-17 months

30 (34%)

42 (42%)

72 (380/0)

18 months or longer

16 (180/0)

23 (23%)

39 (21 %)

87

101

188*

9

3

12

Total *Missing data

Table 6.1: Original sample by time out of prison on 30 June 1999 Inciardi, J., Martin,S., Butzin, C. A., Hooper, R. M., and Harrison L. D. (1997), 'An Effective Model of Prison-Based Treatment for Drug-Involved Offenders', Journal of Drug Issues 27(2), 261-278 at p.262 5 Eight men had not been released by 30 June 1999 and the release dates of a further four men were not available.

4

60 Drug Treatment in Prison

6.5

The analysis of this data revealed that about a third of the original sample had acquired a subsequent conviction since release. Graduates of the RAPt programme were, however, significantly less likely than the non-graduates to fall into this category. Only two in every ten graduates had acquired another conviction in comparison with four out of ten non-graduates (see Table 6.2).

Whether reconvicted post-release

Status Graduates

Non-Graduates

Total

Yes

19 (200/0)

41 (39%)

60 (300/0)

No

76 (80%)

63 (61 %)

139 (70%)

Total

95

104

199*

*Missing data

0

1

1

Table 6.2: Status of original sample by whether reconvicted post-release

6.6

6

Clearly, the longer the post-release period the greater the risk of reconviction. When only those men with post-release periods of 12 months or longer are considered, graduates are still less likely than non-graduates to have acquired a subsequent conviction. A little over a quarter of the graduates who had been released for a year or longer had been reconvicted, in comparison to half of the nongraduates (see Table 6.3). Interestingly, the overall reconviction rate of 42 per cent is consistent with the reconviction rate of 40 per cent calculated by the Home Office for all ex-prisoners followed up 12 nl0nths after release. 6

See Kershaw, C. (1999), 'Reconviction of Offenders Sentenced or Discharged from Prison in 1994, England and Wales', Honle Office Statistical Bulletin 19/99, London: Home Office, for information on reconviction of general prison population.

Crinlinal Behaviour 61

Status

Reconviction

12 months +

Total

Graduates

Non-graduates

Yes

13 (28%)

34 (52%)

47 (420/0)

No

33 (72%)

31 (48%)

64 (58%)

46

65

111

Total

Table 6.3: Reconviction after post-release period of 12 months for graduates and non- graduates

6.7 There are many factors known to influence the likelihood of recidivism: age, the number and nature of previous convictions and the length of criminal career being some of the most important. It was noted earlier in Chapter 3 that in the original sample the profiles of the graduates and non-graduates differed in some respects. 7 These differences, however, do not account for the variations in their rates of reconviction, largely because these characteristics tend to weigh against the graduate population, increasing rather than decreasing the probability of them acquiring a subsequent conviction. This was borne out by an examination of the number of their previous convictions. The graduates who had not been reconvicted shared an average of 13 previous convictions in comparison to eleven amongst the non-graduate group (see Table 6.4). 6.8 The subsequent convictions of the original sample encompassed a broad spectrum of crime, although six out of ten were for burglary or theft, fraud, deception and handling. s The relatively small number of men reconvicted precluded any detailed comparison between the offences of graduates and non-graduates, although it is noteworthy that none of the graduates had been convicted of a drugs offence in comparison with five (12 per cent ) of the non-graduates. Both groups were, however, equally likely to receive a prison sentence: half of the reconvicted graduates and non-graduates were returned to prison.

7

8

See para. 3.3. See Appendix Il, Table 3 for list of offence categories.

62

Drug Treatment in Prison

Number previous convictions

Status Graduates

Non-Graduates

Total

1 (1 % )

6 (9%)

7 (5%)

1-4

17 (23%)

15 (23%)

32 (23%)

5-10

18 (240/0)

15 (23%)

33 (24%)

11-19

22 (29%)

14 (22%)

36 (26%)

20+

17 (230/0)

14 (22%)

31 (220/0)

75

64

139

0

Total

Table 6.4: Number of previous convictions of men in original sample who were not reconvicted by status

RECONVICTIONS: THE SUB-SAMPLE 6.9 The sub-sample had slightly longer post-release periods than the original sample. About seven out of ten men had been released from their original prison sentence fOf a year or longer when the reconviction exercise was undertaken. The mean post-release period was 14 months (see Table 6.5).

Graduates

Non-graduates

Total

2 (5%)

2 (6%)

21 (11 % )

6-11 months

11 (270/0)

6 (18%)

54 (29%)

12-17 months

17 (410/0)

16 (48%)

74 (39%)

18 months or longer

11 (27%)

9 (27%)

39 (21 %)

Total

41

33

74*

*Missing data

1

0

1

Status Less than six months

Table 6.5: Status of sub-sample by time out of prison on 30 June 1999

CrinlinaI Behaviour

63

6.10 Data from the Home Office Offenders' Index showed that a total of 25 men, a third of the sub-sample, had acquired a subsequent conviction. Graduates were again, significantly less likely to have been re-convicted (see Table 6.6).

Graduates

Non-graduates

Total

Yes

10 (24%)

15 (47%)

25 (340/0)

No

32 (76%)

17 (53%)

49 (660/0)

Total

42

32

74*

*Missing data

0

1

1

Reconviction postrelease

Table 6.6: Status of sub-sample by reconviction post-release

6.11 American research clearly shows the importance of aftercare in reducing re-arrest and re-incarceration. The numbers in the present study are small but the direction of the findings supports the importance of an aftercare component. In the sub-sample, 13 of the 42 graduates had entered residential aftercare. Of these, only two had been reconvicted (see Table 6.7).

Experience of after care

Convicted post-release

Not convicted

Total

Yes

2 (15%)

11 (85%)

13

No

9 (31%)

20 (690/0)

29

11

31

42

Total

Table 6.7: Aftercare by reconviction of graduates post-release

Reconvictions and tiers of recovery 6.12 The next question to consider in relation to post-release convictions is whether there are any significant differences between those men who had achieved a first or second tier of recovery and those who had continued to use their drugs of choice. The mean time post-

64

Drug Treatment in Prison

release was 14 months, for those who had abstained from using their drugs of choice (Le. those in the first and second tiers of recovery) and for those who had used their drugs of choice. Men in the first tier, however, had experienced the shortest risk periods, a mean of eleven months, contrasting with a mean of 16 months for those in the second tier (see Table 6.8).

Post-release period

First tier of recovery: total abstinence Mean =11 mths

Second tier of recovery: abstained drug of choice only Mean =16 mths

Used drug of choice

Total

Mean = Mean =14 mths

14 mths

Less than 6 months

2 (12%)

0

2 (5%)

21 (11 %)

6-11 months

6 (35%)

2 (12%)

9 (22%)

54 (29%)

12-17 months

7 (41 %)

6 (370/0)

20 (49%)

74 (39%)

18 months or longer

2 (12%)

8 (50%)

10 (24%)

39 (21%)

Total

17

16

41

74*

*Missing data

0

1

0

1

Table 6.8: Tier of recovery by time out of prison on 30 June 1999

6.13 Those who had relapsed by using their drug of choice post-release were significantly more likely to have acquired a subsequent conviction than those in the first and second tiers of recovery. Almost half of those who had used their drug of choice post-release had been reconvicted in comparison with about one in five of those who had abstained (see Table 6.9).

Crinlinal Behaviour 65

Reconvicted

Not reconvicted

Total

First or Second Tier Recovery

7 (21 %)

27 (79%)

34

Used Drug of Choice

18 (44%)

23 (56%)

41

25

50

75

Drug use since release

Total

Table 6.9: Reconvictions by Drug Use

6.14 Although the small sample size precludes any definitive statement, there was a tendency for men who had relapsed and used their drugs of choice to acquire their convictions more rapidly than those in the first and second tiers of recovery (see Table 6.10). Almost six out of ten users who were reconvicted had acquired their conviction within six months after release from their original sentence.

Drug use since release

Less than 6 months

6 months or longer

Total

First or Second Tier Recovery

1

6

7

of

8

7

15

9

13

22*

Used Drug Choice Total

*Missing data

3

Table 6.10: Time to reconviction by drug use

6.15 The men in the first tier of recovery, who claimed to have abstained from all drug use since their release from prison, were the most likely to have avoided a subsequent conviction. Only one man in this group had been reconvicted for an offence committed after his release. All of the 14 men in the first tier of recovery who had returned negative drug tests had remained free of a conviction for a subsequent offence. It should be remembered, however, that, on

66

Drug Treatnlent in Prison

of time and it could therefore be argued that they had a lower risk of reconviction. The small sample size renders further analysis unreliable. 6.16 But notwithstanding their shorter mean period at risk, it should be emphasised that 15 of the 17 men in the first tier of recovery had been released for at least six months and nine of them had been released for a year or more. In assessing the significance of the changes that men in the first tier of recovery had accomplished, it is worth noting some of the qualitative data concerning their criminal histories and drug using profiles. This demonstrates that these men were not skewed in favour of petty offenders or lightweight users (see Table 6.11).

RE-OFFENDING: THE SUB-SAMPLE 6.17 Reconviction rates do not necessarily give an accurate picture of offending behaviour, as clearly not all offences are detected and successfully prosecuted. Although only 24 members of the subsample had been convicted of an offence committed post-release,9 36 men, virtually half the sub-sample, admitted con1mitting at least one criminal offence since leaving prison. 6.18 In keeping with the data on reconvictions men in the first tier of recovery were significantly more likely than the rest to claim that they had not reoffended post release (see Table 6.12).

9

In addition, one man had been convicted of an offence that had been committed prior to his last sentence. This was not counted as a reconviction for the purposes of the present research.

Cri111illal Behaviour 67

Case no.

Offence

Length of last sentence

Previous convictions

Prev. prison

Drug of choice

Length of drug misuse (years)

(years)

5

1

1

Cocaine

14

Violence

2.5

Not known

2

Alcohol

20

7

Robbery

4

4

4

Cocaine

8

10

Armed Robbery

7

26

3

Alcohol + Poly drug

20

34

Drugs

1.5

13

2

Heroin

4

39

Burglary

5mths

60

5

Heroin

15

44

Robbery

5

2

1

Heroin

15

50

Robbery

7

20

7

Heroin

15

56

Drugs

2.5

10

2

Cocaine

9

62

Violence

4

12

5

Alcohol

11

64

Theft

7mths

42

14

Heroin/ Crack

32

69

Armed Robbery

9

1

1

Heroin

6

71

Robbery

3

Not known

2

Heroin

8

76

Conspiracy to defraud

3.75

7

1

Alcohol

25

92

Robbery

5.5

14

5

Heroin/ Cocaine

16

95

Robbery

lyr

3

1

Crack

5

122

Robbery

1.5

2

0

Cocaine

10

1

Drugs

5

Table 6.11: Criminal histories and dmg-using profiles of the 17 men in the first tier of recovery

68

Drug Treatment in Prison

Reoffended

Not reoffended

Total

3 (180/0)

14 (82%)

17

Second Tier Recovery

9 (53%)

8 (47%)

17

Used Drug of Choice

24 (580/0)

17 (42%)

41

Total

36 (480/0)

39 (52%)

75

Drug use since release First Tier Recovery

Table 6.12: Self-reported reoffending by drug use

6.19 Only three of these men said that they had re-offended, yet all of them were amongst the 14 who had returned negative drug tests. The nature of the offences they reported is, however, worthy of note. Two reported paying 'on the spot' fines for fare dodging and the other admitted driving without a licence. The de-escalation in the seriousness of their offending is evident when their previous offending profiles are considered: Case 34: two previous custodial sentences; 13 previous convictions, including burglary, theft, possession of heroin and cannabis with intent to supply, arson, criminal damage and motoring offences.

Case 39: five previous custodial sentences; 60 previous convictions, including burglary, assault, offensive weapons, theft, possession of heroin, motoring.

Case 50: seven previous custodial sentences; 20 previous convictions, including robbery and possession of firearms; burglary, theft, GBH, possession of class A drug with intent to supply.

6.20 The link between continued drug use and re-offending was further underlined by the accounts offered by the men about their own post-release behaviour. Amongst all of those who had not reoffended, irrespective of whether they were graduates or nongraduates of the programme, half stated that it was due primarily to their drug and/ or alcohol rehabilitation. The other half mentioned

Crj,l1inal Behaviollr 69

growing out of crime; the deterrent effect of a prison sentence; or lifestyle changes, in almost equal proportions. RAPt was considered by almost all the non-offending group to have contributed positively towards changing their attitude to crime.

CONCLUSIONS 6.21 The Home Office Offenders' Index revealed that 30 per cent of the original sample had been reconvicted by 30 June 1999. Graduates of the RAPt programme were significantly less likely than the nongraduates to have been reconvicted. The non-graduates were twice as likely as the graduates to have acquired another conviction. 6.22 On average, the graduates in the original sample had been released for shorter periods than the non-graduates and, therefore, could be said to have a lower risk of reconviction. However, when considering only those with post-release periods of 12 months or longer the graduates were still less likely than non-graduates to have acquired a subsequent conviction. Again, non-graduates were almost twice as likely as graduates to have been reconvicted within this period. Other factors that could affect the risk of reconviction, such as the number and nature of previous convictions and the length of criminal career, weighed against the graduate population, increasing rather than decreasing the probability of them acquiring a subsequent conviction. 6.23 The fresh convictions encompassed a broad spectrum of crime, although six out of ten were for burglary or theft, fraud, deception and handling. None of the graduates had been reconvicted for a drugs offence in comparison with five of the 41 non-graduates. Both were equally likely to have received a prison sentence. 6.24 The sub-sample displayed a similar pattern of reconviction. A total of 25 men, one third of the sub-sample, had been reconvicted. Graduates were again half as likely as non-graduates to have acquired a subsequent conviction. 6.25 The likelihood of being reconvicted was significantly related to

continued drug misuse. Those who had relapsed by using their drug of choice post-release were twice as likely to have acquired a subsequent conviction than those in the first or second tiers of recovery. Almost half of those who had used their drug of choice post-release had been reconvicted. 6.26 Those least likely to have acquired a subsequent conviction were the men in the first tier of recovery, namely those who had abstained

70

Drug Treatment in Prison

from all drug use since their release. Graduates dominated this category. Only one man in this group had been reconvicted for an offence committed after his release. All of the 14 graduates in the first tier of recovery who had returned negative drug tests had remained free of a conviction for a subsequent offence. 6.27 Although the numbers in the present study are small, the direction of the findings supports American research that aftercare reduces subsequent contact with the criminal justice system. 6.28 The self-reported data on the commission of criminal offences postrelease revealed that about half of the sub-sample had reoffended. Graduates were just as likely as non-graduates to reveal criminal behaviour but they tended to report extremely minor summary offences that may have been overlooked by other respondents. Only three of the first tier recoverers said that they had re-offended; two reported paying 'on the spot' fines for fare dodging and the other admitted driving without a licence. The de-escalation in the seriousness of their offending is evident when their previous offending profiles are considered. 6.29 The self-reported criminal behaviour mirrored the picture that emerged from the reconviction data in that it revealed a concentration of offending amongst those who had relapsed and used their drug of choice post-release. 6.30 The explanations offered by the men for their criminal rehabilitation

were similar, irrespective of whether they were graduates or nongraduates of the programme. Half of those who claimed that they were no longer offending stated that this was due primarily to their drug and/ or alcohol rehabilitation. RAPt was considered by almost all the non-offending group to have contributed positively towards changing their attitudes to crime.

CHAPTER 7

Interpreting Programme Effectiveness 7.1

The evaluation of drug treatment programmes in England and Wales remains an undeveloped area of social policy research. Within the criminal justice system the growth of treatment interventions has outpaced the assessment of their effectiveness and their relevance to particular groups of users. The evaluative research that has taken place has tended to focus on 'processes' rather than 'outcomes'. In other words, they have tended to examine how the programmes operate, and the self-assessment of participants during treatment, rather than the extent to which a specific intervention is associated with subsequent reductions in drug use and criminal conduct. 1 Despite the relatively recent emphasis on drug services in prisons little is known about the extent to which prisoners who have completed programmes of treatment have changed their behaviour post-release. The difficulties and expense of undertaking outcome studies provides part of the explanation for this gap in the literature. The present study has attempted to fill a small part of this void by examining the impact that RAPt treatment programmes have had on their participants. It has shown that following their release from prison, graduates of the RAPt programme have been more likely than nongraduates to abstain from drug use and less likely to have been reconvicted after 12 months. But how should this information be interpreted? In many respects, such data provide the starting point of an evaluation rather than its conclusion.

7.2

Whether RAPt provides a successful programme of treatment depends very much on how success is to be gauged. One way of assessing the data is from a cost-effectiveness standpoint. The type of drug users receiving treatment from RAPt are said to cost the criminal justice system in excess of £5,000. per head, per annum, or £0.5 billion in total. 2 Social Security costs are likely to be of a similar

See Hough, M. (1996), Proble,n Drug Use and Crinlinal Justice: A Revielv of the Literature Drug Prevention Initiative Paper No. 15, London, Home Office Central Drugs Prevention Unit; Home Office (1999), Drugs Interventions in the· Crinlinal Justice Syste,,,: London, Home Office. 2 Edmunds, M., Hough, M., Turnbull, P.}. and May, T. (1999), Doing Justice to Treatnlent: Referring offenders to drug services, Drugs Prevention Advisory Service, Paper 2, London: Home Office, at p.7.

1

72

Drug Treatment in Prison

order and there are further costs incurred for the health services. The average cost of a RAPt programme is £2,000 per head per annum, or approximately £500 per placement. The precise savings cannot be estimated here, suffice to say that, from an econometric perspective, RAPt needs relatively few of these serious offenderaddicts to abstain from drug use and crime, eve11 for relatively short periods of time, for there to be a likely reduction in public expenditure. 3 7.3

The evidence from the present study-that graduates fare better, in relation to subsequent drug use and criminal convictions, than a comparable group who have not experienced the programme (the non-starters), or have had only partial exposure to it (the dropouts}-appears to support the statement that 'treatment seems better than no treatment'. But does the RAPt programme offer treatment outcomes that are better, or worse, or equal to the outcomes produced by other programmes? This question is of fundamental importance to those responsible for selecting between competing contractors for drug programmes in prisons.

7.4

To assess the relative success of the RAPt programme it is necessary to have a benchmark against which to judge its performance. At present, there are no comparative data for drug treatment programmes operating in other prisons in England and Wales. Consequently, it is necessary to look to research that has been conducted in other jurisdictions, notably in North America where evaluative studies on prison-based drug treatment programmes are arguably most developed.

7.5

Evaluations of three therapeutic community-based drug treatment programmes operating in· prisons in the United States provide a context within which the success of the RAPt programme might be assessed. These are the Key-Crest programme in Delaware; the Amity programme in San Diego, California; and the Kyle New

Vision programme in Texas.

3

It is worth bearing in mind that the average man in the first tier of recovery had a sentence of just over five years, three previous prison sentences and an addiction, mainly to illicit class A drugs, stretching for almost 14 years.

Interpreting Progranlnle Effectiveness 73

KEY-CREST PROGRAMME 7.6

The Key-Crest programme operates in the correctional system of Delaware. It is built around three therapeutic communities: the Key, a prison-based therapeutic community (TC) for men; WCI Village, a prison-based TC for women; and Crest a residential work-release centre for inmates on parole. The programme was evaluated by comparing three groups of inmates who had experienced different

levels of treatment together with a control group drawn from the 4

general prison population. Inmates at the first level of treatment had undergone the Key prison-based programme only. Those in the second phase had attended the Crest, a TC-based work-release programme following their release on parole. The final treatment phase included supervised outpatient after-care. A total of 448 men were followed up 18 months after their release and their patterns of drug use and re-arrest data were compared for the four groups of respondents. 7.7

The hypothesis was that offenders receiving primary treatment in prison followed by secondary treatment in a work-release TC, followed by after care would have more successful outcomes than those who had experienced fewer stages of treatment. The findings showed that those who had po'st-release interventions had significantly higher arrest-free and drug-free rates compared to those who had only the prison-based treatment or those in the control group who had no exposure to treatment at all. The men who had experienced only the Key programme had similar rates of re-arrest to the control group. Over half of the control (54 per cent, n=180) and Key (57 per cent, n=37) groups had been arrested within 18 months of their release. This compared with 43 per cent of the Crest group (n=179) that had work-release experience and less than one quarter (23 per cent, n=43) of the Key-Crest group that had a full after-care programme.

7.8

Drug use post-release followed a similar pattern, whereby the lowest rates of relapse correlated with greatest exposure to treatment. The Key-Crest group had the lowest rate of relapse (53 per cent), followed by the Crest group (69 per cent) and finally the Key (79 per cent) and control (84 per cent) groups.

4

Inciardi, J. A., Martin,S. 5., Butzin, C. A., Hooper, R. M. and Harrison, L. D. (1997), 'An Effective Model of Prison-Based Treatment for Drug-Involved Offenders, Journal of Drug Issues, 27 (2) 261-278.

74 Drug Treatment in Prison

AMITY PROGRAMME 7.9 The Amity Programme is a modified therapeutic community programme located in Donovan prison in San Diego. It provides treatment over a 12 month period for 200 inmates nearing the end of their sentence. Following release they are given the option of being admitted to a community based TC for transitional after-care. The evaluative research compared the post-release behaviour of 715 men who were divided into five groups: those who had completed both the prison-based programme and the community-based residential after-care (n=97); those who completed the prison programme but dropped-out of the after-care programme prematurely (n=36); those who had completed the prison-based programme only (n=194); those who had started the prison-based programme but did not complete it (n=98); and finally, an untreated control group (n=290).5 7.10 The outcome measure in this study in relation to subsequent criminality was not re-arrest or reconviction but reincarceration within one year of release. The findings were in keeping with those for Key-Crest namely, that those men who had completed residential after-care had significantly lower rates of reincarceration than the other groups. Only eight per cent of those who had completed after-care were re-imprisoned in comparison to about four out of ten inmates in each of the other groups. 7.11 In relation to subsequent drug use those who had completed both the prison-based and after-care programmes had the lowest rates of relapse. Again, only a quarter of those with experience of after-care had used an illicit drug in comparison to two-thirds of the other 6 groups.

KYLE NEW VISION 7.12 The New Vision TC programme in Kyle, Texas provides treatment to 500 inmates during the final nine months of their sentence. After release on parole they are required to attend three months Wexler, H. K., De Leon, G., Kressel, D., and Peters, }. (1999), 'The Amity Prison TC Evaluation: Reincarceration outcomes', Crinlinal Justice and Behaviour, 26 (2) 147-168 6 See Lowe, L., Wexler, H. K. and Peters}. (1998), The R. J. Donovan In-prison and Conlnlunity Substance Abuse Program: Three year return to custody data, Sacremento CA: Office of Substance Abuse Programs, California Department of Corrections; Hiller, L., Knight, K. and Simpson, D.D. (1999) 'Prison-based substance abuse treatment, residential after-care and recidivism', Addiction 94(6), 833-842.

5

Interpreting Programme Effectiveness 75

residential after-care in a transitional therapeutic community. This is followed by supervised out-patient after-care for up to one year. 7.13 A programme evaluation compared the post-release behaviour of 297 men who were categorised into three groups: those who had transitional after-care (n=145); those who had experience of the prison-based treatment but who failed to finish the transitional programme (n=77); and an untreated group (n=75). The first evaluation was conducted six months after release. It showed that

three per cent of those in the after-care group had been rearrested compared with 15 per cent of those with only prison-based treatment and 16 per cent of those in the untreated control group.7 7.14 Men who had experienced after-care also had lower rates of drug use. Hair specimens collected over a six month follow-up period on a sample of 396 men showed that 35 per cent of those who had completed both the prison-based and community treatment (n=170) returned positive results for cocaine, the primary drug of choice for the sample. This compared with 47 per cent who had experienced only the programme in prison (n=123) and 54 per cent for the untreated group (n=103).8

7.15 The treatment group of 293 men, together with a matched control group of 103, were subsequently followed up between 13 and 23 months post-release. 9 This showed that those who had completed after-care were significantly less likely than the control group to be rearrested. The men who had completed only the prison programme however, did not have a significantly lower probability of arrest. Thirty per cent of the after-care group had been rearrested, as had 36 per cent of those who had completed the prison programme only, and 42 per cent of the untreated control group.

RAPt COMPARED 7.16 Considerable caution must be exercised in drawing comparisons between the outcome measurements in the American studies and Knight, K., Simpson, D. Chatham, L. R. and Camacho, L. M. (1997) , 'An Assessment of Prison-Based Drug Treatment: Texas' In-prison Therapeutic Community Programme', Journal of Offender Rehabilitation, 24, 75-100. 8 Knight, K, Hiller, M. L., Simpson D. D. and Broome, K. M. (1998), 'The Validity of SelfReported Cocaine Use in a Criminal Justice Treatment Sample', A111erican Journal of Drug and Alcohol Abuse, 24, 647-660. 9 Hiller, M. L., Knight, K. and Simpson, D. D. (1999), 'Prison-Based Substance Abuse Treatment, Residential After-Care and Recidivism', Addiction, 94 (6) 833-842.

7

76 Drug Treatnlent in Prison

those from the present study of RAPt. There are important differences in the scale of the studies and their methodologies. Most significantly, the American research has larger samples, longer follow-up periods and the measurements of criminal activity have been based on rearrest or reincarceration data rather than reconvictions. There may also be important differences in the activities of the police and the courts in the different jurisdictions that result in different measurements being recorded. 7.17 Given these discontinuities between the data sets it might be argued that there is little to be gained from any comparative analysis. On the other hand, the American research does provide an indication of the levels of success achieved by other prison-based programmes, albeit that these operate on a larger scale and with more extensive after-care facilities. Without stretching the comparative analysis too far, the criminal behaviour and subsequent drug use of the RAPt graduates will be set alongside that of their American counterparts. Due, however, to the lack of a formal after-care component linked to the RAPt programme, comparisons have been limited to the American samples that experienced prison-based treatment only and the limited number of RAPt graduates who had residential aftercare were excluded from the analysis. Criminal behaviour 7.18 Data from the present study refers to the outcomes for RAPt graduates who had been released from their original sentenc;e for 12 months or longer. The main points of comparison can be distilled as follows:

Key: 57 per cent rearrested-follow up period after 18 months (n=37)

Amity: 40 per cent reincarcerated-follow up period after 12 months (n=194) Kyle: 36 per cent rearrested-follow-up period after 13 months (n =123)

RAPt: 29 per cent reconvicted-follow-up period after 12 months (n=38)

Interpreting Programme Effectiveness 77

Drug use 7.19 Key: 53 per cent drug free -follow up period 18 months (n=24)

Amity: 34 per cent drug free-follow up period 12 months

10

Kyle: 53 per cent free of drug of choice-follow up period six months (n=77)

RAPt : 54 per cent free of drug of choice-follow up period six months (n =28) 53 per cent free of drug of choice-follow up period 12 months (n=19).

CONCLUSIONS 7.20 Despite the recent emphasis on drug treatment programmes in prisons little investment has been made in evaluative studies that assess treatment outcomes in relation to reduced drug use and recidivism post-release. The present study has attempted to fill a small part of this void by comparing the post-release behaviour of a group of RAPt graduates with that of a group of programme dropouts and a group of non-starters who applied for a place in treatment but who never started the programme. The earlier chapters have shown that the graduates have been more likely than non-graduates to abstain from drug use and less likely to be reconvicted within a year of release. But how should this success be gauged? 7.21 One means of assessing the value of the programme is to evaluate its cost-effectiveness. A detailed analysis is beyond the scope of this study but relatively crude comparisons show unequivocally the potential for RAPt to offer significant reductions in public expenditure. 7.22 Another approach to assessing the relative success of the RAPt programme is to compare its performance against that of other drug treatment programmes in prisons. No comparative data exist for programmes in this country but a broadly based comparative analysis can be drawn with evaluative studies from North America, namely: the Key-Crest programme in Delaware; the Amity

10

Sample size not reported

78 Drug Treatment in Prison

Programme in San Diego, California; and the Kyle-New Vision programme in Texas. 7.23 Considerable caution must be exercised when comparing the data from the different studies. Differences in their scale and their methodologies preclude a precise quantitative analysis and require any comparative interpretation to be broadly drawn. Taken from this perspective, the data on subsequent drug use and measures of recidivism indicate that the outcomes for RAPt graduates are at least as good as those recorded for inmates in the United States of America who have received prison-based treatment without a formal after-care component. 7.24 The most striking finding from the American research is the significant effect that residential after-care and transitional treatment facilities have on reducing drug relapse and the likelihood of recidivism. Investing in the reform of the poorly developed network of post-release support that operates in this country is an obvious priority if the effectiveness of prison-based programmes is to be advanced. The post-release experiences of men in this study, detailed in Chapter 4, clearly demonstrate the need for more systematic support structures that address the longrecognised relationship between the material deprivations associated with unemployment and poor housing and the opportunities for crime and substance misuse that thrive in such environments.

CHAPTER 8

Summary of Main Findings 8.1

The original prison sample (n=200) comprised a relatively serious group of recidivist offenders with extensive prison experience. Only seven men had no previous convictions. The graduates of the RAPt programme, however, had the most entrenched criminal profile, in that they were serving longer sentences and were more likely to have a criminal history that included convictions for violence and drugs offences. Virtually everyone believed that their offending was drug-related and most of the men said that their drug use was the main cause of their offending behaviour.

8.2

Typically, the men in this study had long histories of substance misuse: the average length of addiction was 13 years for graduates and ten years for non-graduates. Before their current sentence almost everyone was regularly using their substance of choice, usually on a daily basis. The majority of men in the sample were polydrug users but the single most common drug of choice was heroin.

8.3

Drug use in prison was widespread and regular use of cannabis and heroin was common. Half the sample had used heroin during their present sentence and one in three had drunk alcohol. Few men felt that the introduction of mandatory drug testing (known as 'MDT') had affected their consumption. There were surprisingly few positive tests recorded even for those men admitting daily use of heroin.

8.4

Contact with RAPt, whether as members of the pre-admission group or as participants on the primary programme, was associated with a significant shift in the inmates' drug-using behaviour in prison. A majority of the sample said that they had abstained from all drug use during their period of contact with RAPt. Graduates, however, were significantly more likely than the other men to nlaintain a drug-free lifestyle in prison after their formal contact with RAPt had ceased.

8.5

Participation in the RAPt, programme was held by the men to be a positive experience that had assisted them to control their drug and/ or alcohol problem. The benefits of the programme, however, were thought to extend beyond drug rehabilitation and to encompass a broader sense of personal development and general

80 Drug Treatnlent in Prison

attitudinal changes that had pro-social consequences for their behaviour in prison as well as for their personal relationships outside. 8.6

In relation to their post-release plans, a degree of equivocation was expressed about the need to adopt a completely drug-free lifestyle. This was particularly notable in relation to the consumption of alcohol but was also evident in respect of the use of cannabis. Graduates, however, were twice as likely as non-graduates to accept the risks of cross-addiction and to say that they intended to abstain from all drug use after leaving prison.

SOCIAL CIRCUMSTANCES POST-RELEASE 8.7

The sub-sample of 75 inmates who were contacted after their release from prison typically had a network of interpersonal supports, provided primarily by their family of origin but also by their wives or partners. In most cases the men returned to accommodation they had lived in prior to their last sentence or found accommodation in the same area. Only 13 men were admitted into a residential secondary care programme after release. Almost all the men had a circle of friends or social contacts, mainly people they had known before their last sentence. Most strikingly the social world in which these men existed exposed them to regular contact with people who misused drugs and/ or alcohol.

8.8

The overrepresentation of men with family and other social ties is likely to be due to the method of contacting respondents after their release from prison. Inevitably it was easier to find men with established ties in the community than those who had a more rootless lifestyle.

8.9

A quarter of the sub-sample had returned to prison by the time they were re-interviewed. Amongst the rest, only half of the men were living in accommodation that they regarded as permanent. Although half the men were currently in employment few had secured a permanent full-time job and half of the sub-sample was living primarily on state benefits.

8.10 The social circumstances varied little between the graduate population and the drop-outs and non-starters. However, the graduates were more likely to have received the formal support of residential drug treatment following their release and they had been more successful in finding employment (although not full-time

Sunlmary of Main Findings

81

work) and in establishing new social contacts that did not misuse drugs or alcohol.

DRUG USE POST-RELEASE 8.11 The original sample of 200 men interviewed in prison reported a significant reduction in illicit drug use following their contact with RAPt. Two-thirds of these men said that they had abstained from using all drugs since enrolling on the pre-admission group or joining the programme. The responses of the sub-sample were identical: two out of three claimed that they had successfully avoided all drug use for the rest of their time in prison. 8.12 Despite their ability to abstain from all substances in prison, the majority of the sub-sample relapsed after their release. It is, however, widely recognised that the process of recovery from addiction is frequently characterized by periods of relapse. In the light of this, the depiction of recovery as a one-dimensional concept, defined solely in terms of whether or not drug use has occurred, is analytically naIve and empirically misleading. In this research, recovery is depicted as a hierarchical model consisting of four broad levels of achievement:

• First Tier Recovery-abstinence from all substances since release • Second Tier Recovery-abstinence from drug of choice only since release • Relapse Recovery-relapse post-release but subsequently establishing a first or sec'ond tier recovery • Reduction of use-less frequent use of drug of choice.

8.13 The First Tier of Recovery is characterized by abstention from all drug and alcohol use post-release. Graduates of the RAPt programme dominated this group: 16 of the 17 men claiming this level of

recovery were graduates of the primary programme. The exception was a drop-out but he had spent two months on the programme and was convinced that the RAPt course had played a central role in facilitating his recovery. Residential secondary care and contact with self-help organisations post-release were associated with a greater likelihood of first tier recovery.

82

Drug Treatment in Prison

8.14 The Second Tier of Recovery is characterized by abstention from drugs of choice. Men in this category admitted using some substances since their release but said that they had abstained from their drugs of choice. There were 17 men who laid claim to this level of recovery and the substances they were most likely to have used were cannabis, alcohol or both. These men were, however, just as likely to be non-graduates as graduates. 8.15 All those claiming first or second tier recovery were asked to submit to a drug test. Test results confirmed the self-reported claims in about 80 per cent of the cases and confirmed that 40 per cent of all graduates followed up after their release, had achieved at least the second tier of recovery, in comparison with only 12 per cent of all non-graduates in the sub-sample. 8.16 Those who identified alcohol as their drug of choice were significantly more likely to have returned to its use. The alcoholic group are especially vulnerable to relapse due to the legality and widespread availability of their drug of choice.

8.17 Relapse Recovery was achieved by about half the men who had used substances post-release, irrespective of whether they had relapsed by using their drugs of choice or other substances. Although more graduates than non-graduates managed to recover from a relapse and to establish a drug-free lifestyle, this difference did not reach a level of statistical significance.

8.18 Reduction of Use. A little over half the sub-sample had used their drug of choice post-release and half of these men admitted that they were still doing so at the time of their follow-up interview. Nevertheless, there was an indication that their level of use had declined. There appeared to be no significant difference between graduates and non-graduates in this respect. However, the nine graduates who were currently using their drug of choice were significantly less likely than the others to believe that their use was under control. Only one graduate thought his drug use was under control in comparison with three-quarters of the non-graduate users. 8.19 It would appear that the impact of RAPt is most significant in enabling graduates to establish a drug-free lifestyle. When account is taken of those men in the first tier of recovery, together with those who initially relapsed but who subsequently claimed to be drug-free, graduates were twice as likely as non graduates to have reached this level of recovery. Two-thirds of graduates

Sunln1ary of Main Findings 83

claimed to be currently ,in the first tier, in comparison to only a third of the non-graduates.

CRIMINAL BEHAVIOUR POST-RELEASE 8.19 The Home Office Offenders' Index revealed that 30 per cent of the original sample had been reconvicted by 30 June 1999. Graduates of the RAPt programme were significantly less likely than the nongraduates to have been reconvicted. Twice as many non-graduates as graduates had acquired another conviction. 8.20 The longer the post-release period the greater the risk of reconviction. However, among men with post-release periods of 12 months or longer, graduates were still less likely than nongraduates to have acquired a subsequent conviction. Again, almost twice as many non-graduates as graduates who had been released for a year or longer had been reconvicted. The mean post-release period was 14 months. 8.21 The fresh convictions encompassed a broad spectrum of crime, although approaching half of them were categorised as theft, fraud, deception and handling. There appeared to be no significant differences between graduates and non-graduates in the types of offences for which they had been convicted. Both were equally likely to have received a prison sentence. 8.22 Those who had relapsed by using their drug of choice postrelease were significantly more likely to have acquired a subsequent conviction than those in the first and second tiers of recovery. Almost half of those who had used their drug of choice post-release had been reconvicted. 8.23 Those least likely to have a subsequent conviction were the men in the first tier of recovery, who had abstained from all drug use since their release. Graduates dominated this category. Only one man in this group had been reconvicted for an offence committed after his release. All of the 14 men in the first tier of recovery who had returned negative drug tests had remained free of a conviction for a subsequent offence. 8.24 Although the numbers in the present study are small, the direction of the findings supports American research into the importance of an after-care component. In the sub-sample 13 of the 42 graduates had entered residential after-care. Of these, only two had been reconvicted.

84

Drug Treatment i11 Prison

8.25 The self-reported data on the commission of criminal offences postrelease revealed that about half of the sub-sample had reoffended. Graduates were just as likely as non-graduates to reveal criminal behaviour but they tended to report extremely minor summary offences which other respondents overlooked as irrelevant. Only three of the first tier recoverers said that they had re-offended; two reported paying 'on the spot' fines for fare dodging and the other admitted driving without a licence. The de-escalation in the seriousness of their offending is evident when their previous offending profiles are considered. 8.26 In line with the reconviction data on the sub-sample, the selfreported offending tended to be concentrated amongst those who had relapsed and used their drug of choice post-release. 8.27 Amongst all of those who had not re-offended, irrespective of whether they were graduates or non-graduates of the programme, half stated that it was due primarily to their drug and/or alcohol rehabilitation. RAPt was considered by almost all the non-offending group to have contributed positively towards changing their attitude to crime.

INTERPRETING PROGRAMME EFFECTIVENESS 8.28 Despite the recent emphasis on drug treatment programmes in prisons little investment has been made in evaluative studies that assess treatment outcomes in relation to reduced drug use and recidivism post-release. The present study has attempted to fill a small part of this void by comparing the post-release behaviour of a group of RAPt graduates with that of a group of programme dropouts and a group of non-starters who applied for a place in treatment but who never started the programme. The earlier chapters have shown that the graduates have been more likely than non-graduates to abstain from drug use and less likely to be reconvicted within a year of release. But how should this success be gauged? 8.29 One means of assessing the value of the programme is to estimate its cost-effectiveness. A detailed analysis is beyond the scope of this study but relatively crude comparisons show unequivocally the potential for RAPt to offer significant reductions in public expenditure. 8.30 Another approach to assessing the relative success of the RAPt programme is to compare its performance against that of other drug

Sunll11ary of Main Findings

85

treatment programmes in prisons. No comparative data exist for programmes in this country but a broadly based comparative analysis can be drawn with evaluative studies from North America, namely: the Key-Crest programme in Delaware; the Amity programme in San Diego, California; and the Kyle-New Vision programme in Texas. 8.31 Considerable caution must be exercised when comparing the data from the different studies. Differences in their scale and their

methodologies preclude a precise quantitative analysis and require any comparative interpretation to be broadly drawn. Taken from this perspective, the data on subsequent drug use and measures of recidivism indicate that the outcomes for RAPt graduates are at least as good as those recorded for inmates in the United States who have received prison-based treatment without a formal aftercare component. 8.32

T~e most striking finding from the American research is the significant effect that residential after-care and transitional treatment facilities have on reducing drug relapse and the likelihood of recidivism. Investing in the reform of the poorly developed network of post-release support that operates in this country is an obvious priority if the effectiveness of prison-based programmes is to be advanced. The post-release experiences of men in this study, detailed in Chapter 4, clearly demonstrate the need for more systematic support structures that address the longrecognised relationship between the material deprivations associated with unemployment and poor housing and the opportunities for crime and substance misuse that thrive in such environments.

Appendix I

Comparative Data for Original Sample, Sub-sample and Reconvicted Sample 1. AGE Sample Original Sample (n=200) Sub-Sample (n=75) Reconvicted Sample

A~e ran~e

Mean age 32 32 31

21-62 21-62 21-55

(n=60)

2. RACE

Sample

Original Sample (n=200) Sub-Sample (n=75)

ReconvictedSample (n=60)

White

Race African!AfricanCaribbean

147 (73.5 %)

36 (18 0/0)

54 (72 0/0) 41 (68 0/0)

16 (21 0/0) 16 (27 %)

South Asian and Other 6 (3 %) 0 0

Other

Total

11 (5.5 %)

200

5 (7 %) 3 (5 %)

75 60

Appendix I 87 3. ORIGINAL MAIN OFFENCE

Offence

Violence Burglary Robbery Theft/Fraud

Original sample

Sub-sample

Reconvicted sample

26 (13 %) 45 (23 %) 32 (16 %) 30 (15 %)

6 (8 %) 16 (21 %) 18 (24 0/0) 12 (16 %) 9 (12 %) 12 (16 %) 2 (3 %)

6 (10 %) 18 (30 %) 8 (13 %) 12 (20 %) 7 (12 %) 8 (13 %) 1 (2 0/0) 60

Motoring

23 (12 0/0)

Drugs Other Total

38 (19 %) 6 (3 %) 200

75

4. SENTENCE LENGTH

Sample Original Sample (n=200) Sub-Sample (n=75) Reconvicted Sample

Sentence range (months) 2-312

Mean sentence (months) 36

3-144 3-144

36 31

Range of previous convictions 0-60

Mean number of previous convictions 14

0-60 1-60

15 20

(n=60)

5. PREVIOUS CONVICTIONS

Sample Original Sample (n=200)

Sub-Sample (n=75) Reconvicted Sample (n=60)

88 Drug Treatment in Prison

6. PREVIOUS CONVICTIONS FOR VIOLENCE Previous convictions for violence 119 (60 %)

No violence convictions 81 (40 %)

Sub-Sample (n=75)

47 (63 %)

28 (37 %)

Reconvicted Sample

40 (67 %)

20 (33 %)

SAMPLE

Original Sample (n=200)

(n=60)

7. PREVIOUS CONVICTIONS FOR DRUGS

Sample

Original Sample (n=200, missing data 2) Sub-Sample (n=75) Reconvicted Sample

Previous convictions for drugs 95 (48 %)

No drugs convictions

33 (440/0)

42 (56 %)

28 (47 %)

31 (52 0/0)

103 (52 %)

(n=59, missing data 1)

8. PREVIOUS CUSTODIAL SENTENCES Sample

Original Sample

Range of previous custody 0-17

Mean number of previous custody 4

0-17 0-17

5

(n=200)

Sub-Sample (n=75) Reconvicted Sample (n=60)

6

Appendix I

89

9. DRUG OF CHOICE Drug of choice

Original sample

Sub-sample

Reconvicted sample

Cannabis Heroin Cocaine Ecstasy / Amphetamines Alcohol Polydrug Drug and Alcohol Heroin and Cocaine Other Missing Data Total

11 (5 0/0) 58 (29 0/0) 38 (19 0/0) 15 (8 0/0)

1 (1 0/0) 20 (27 0/0) 14 (19 0/0) 3 (4 0/0)

1 (2 0/0) 21 (35 0/0) 11 (18 0/0) 7 (12 0/0)

40 (20 %)

14 (19 %)

10 (17 0/0)

14 (70/0) 19 (10 0/0)

7 (9 0/0) 7 (9 0/0)

3 (5 0/0) 5 (8 0/0)

No data

9 (12 %)

No data

4 (2 0/0)

0

1

0 75

2 (3 0/0) 0

200

60

10. LENGTH OF ADDICTION Length of addiction Less than 1 yr 1-5 yrs

6-10 yrs

Ori~inal sample

Graduate

1 (1 0/0)

14 (14 0/0) 29 (29 °/0)

11-20 yrs

41 (41 0/0)

10

20 yrs+ Missin~

Mean

(10 0/0)

data

13 yrs

NonGrad 2 (2 0/0) 26 (27 %) 35 (370/0) 32 (340/0)

5 (5 0/0) 5 10 yrs

Sub-sample NonGraduate Grad 0 0

5 (12 %) 10 (24 °/0) 24 (57 0/0) 3 (7 01o)

9 (27 %) 14 (42 0/0) 8 (24 0/0) 2 (6 0/0)

13 yrs

10 yrs

I

Reconvicted sample Graduate NonGrad 0 1 (2.5 0/0) 4 11 (21 %) (27.5 %) 5 14 (35 0/0) (26 °/0) 9 11 (47.5 0/0) (27.5 0/0) 1 3 (7.5 0/0) (5.5 °/0) 1 12 yrs 10 yrs

Appendix 11: Miscellaneous Tables

Months postrelease

Less than six months 6-11 months

First Tier

Recove ry level Currently Second Clean Tier after Relapse

Relapsed

Total

4

3

1

1

10

12

10

10

21

53

12-19

1

4

4

3

12

months Total

17

17

15

26

75

Table 1: Recovery level of sub-sample by length of time post-release

Result Type of test Urine Hair Breath No Test Total

Total 4 18

5

Negative 4 13

0

4

4

-

-

49

8

21

75

Positive 0

Table 2: Types of dmg tests by results.

Appendix 11 91

Offence Violence Against the Person Theft, Fraud. Deception etc. Robbery Burglary Drugs Motoring Sexual Offences Breach of Licence/ Bail Conds. Other

Total

Status Non-Graduates 4 (10% )

1

(20/0 ) 4 (10% ) 5 (12% ) 5 (120/0 ) 1 (2% ) 2

Total 5 (80/0 ) 26 (43% ) 3 (5% ) 10 (17% ) 5 (80/0 ) 6 (10% ) 1 (20/0 ) 3

(5% )

(5% )

(5% )

1 (5% )

0

1 (2% )

19

41

60

Graduates 1 (5% ) 7 (37% ) 2 (100/0 ) 6 (32% ) 0 1 (5% ) 0

19 (46% ) 1

Table 3: Status by reconvicted offence

APPENDIX Ill: The 12 Steps Step 1

We admitted that we were powerless over our addiction, that our lives had become unmanageable.

Step 2

We came to believe that a Power greater than ourselves could restore us to sanity.

Step 3

We made a decision to turn our will and our lives over to the care of God as we understood Him.

Step 4

We made a searching and fearless moral inventory of ourselves.

Step 5

We admitted to God, to ourselves and to another human being, the exact nature of our wrongs.

Step 6

We were entirely ready to have God remove all these defects of character.

Step 7

We humbly asked Him to remove our shortcomings.

Step 8

We made a list of all persons we had harmed and became willing to make amends to them all.

Step 9

We made amends to such people whenever possible, except when to do so would injure them or others.

Step 10

We continued to take personal inventory and when we were wrong promptly admitted it.

Step 11

We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Step 12

Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs.

Bibliography Alcoholics Anonymous (1993), Twelve Steps and Tlvelve Traditions 22nd Printing, New York, Alcoholics Anonymous Anderson, D. J. (1981), Perspectives on Treatment: The Minnesota experience Minnesota, Hazelden Foundation Ball, J. C., Shaffer, J. W. and Nurco, D. N. (1983), 'Day-to-Day Criminality of Heroin Addicts in Baltimore: A study in the continuity of offense rates', Drug and Alcohol Dependence, 12, 119 -142 Edgar, K. and O'Donnell, I. (1998), MandatonJ Drug Testing in Prisons: The relationship between MDT and the level and nature of drug misuse, Home Office Research Study 189, London, Home Office Research and Statistics Directorate Edmunds, M., Hough, M., Turnbull, P. and May T. (1999), Doing Justice to Treatment: Referring offenders to drug services, London, Drugs Prevention Advisory Service Paper No. 2 Hiller, M. L., Knight, K. and Simpson, D. D. (1999), 'Prison-Based Substance Abuse Treatment, Residential After-Care and Recidivism', Addiction, 94(6) 833-42 Home Office (1999), Drugs Interventions in the Criminal Justice Systenl, London, Home Office Hough, M. (1996), Problem Drug Use and Criminal Justice: A revielv of the literature, Drug Prevention Initiative Paper No. 15, London, Home Office Central Drugs Prevention Unit Johnson, B. D., Goldstein, E., Preble, E., Schmeidler, D. 5., Lipton, D. 5., Spunt, B and Miller T. (1985), Taking Care of Business: The econonlics of crinle by heroin users Lexington, MA, Lexington Books Kershaw, C. (1999), 'Reconviction of Offenders Sentenced or Discharged from Prison in 1994, England and Wales', Home Office Statistical Bulletin 19/99, London, Home Office Knight, K., Hiller, M. L., Simpson, D. D. and Broom, K. M. (1998), 'The Validity of Self-Reported Cocaine Use in a Criminal Justice Treatment Sample', Anlerican Journal of Drug and Alcohol Abuse, 24, 647-660

94 Drug Treatnlent i11 Prison

Knight, K., Simpson, D. D., Chatham, L. R. and Camacho, L. M. (1997), 'An Assessment of Prison-Based Drug Treatment: Texas' in-prison therapeutic community programme', Journal of Offender Rehabilitation, 24, 75-100 Office for National Statistics (1998), Psychiatric Morbidity A1110ngst Prisoners, London, Stationery Office Peters, R. H. and Murrin, M. (2000), 'Effectiveness of Treatment-based Drug Courts in Reducing Criminal Recidivism', Crinlinal Justice and Behaviour, 27 (1) Wexler, H. K., De Lean, G., Kressel, D. and Peters, J. (1999), 'The Amity Prison Te Evaluation: Reincarceration outcomes', Criminal Justice and Behaviour, 26(2) 147-168.

Index of Tables 1.1 1.2 1.3

Original prison sample by treatment status Sample size by prison Sub-sample by treatment status

3.1 3.2 3.3

Status of original sample by current offence Status of original sample by previous conviction for drug offence Status of original sample by length of addiction Drugs of choice Status of original sample by substance use in prison after contact with RAPt Status of original sample by anticipate drug use post-release Status of original sample by anticipate alcohol use post-release

3.4 3.5 3.6 3.7 4.1

4.2

Status of original sub-sample Status of sub-sample by current employment

5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10

Status of sub-sample by use of any substance post-release Status of sub-sample by used drug of choice post-release Status of users in sub-sample by use of drug of choice Status of sub-sample by pattern of 'other drug' use Status of sub-sample by drug test results Drugs of choice used post-release Current drug use Status of sub-sample that relapsed by current abstinence Status of sub-sample by current use of any substance Status of sub-sample that used drug of choice by current use of drug of choice 5.11 Frequency of persistent use of drug of choice

6.1 6.2

Original sample by time out of prison on 30 June 1999 Status of original sample by whether convicted post-release 6.3 Status of original sample by reconviction 12 months post-release 6.4 Status of original sample not reconvicted by previous convictions 6.5 Status of sub-sample by time out of prison post-release 6.6 Status of sub-sample by reconviction post-release 6.7 After-care by reconviction of graduates 6.8 Tier of recovery of sub-sample by time out of prison on 30 June 1999 6.9 Recovery level of sub-sample by reconviction 6.10 Recovery lev~ of sub-sample by time to reconviction 6.11 Criminal history and drug use of men in first tier of recovery 6.12 Recovery level of sub-sample by self-reported offending.

TPS (216mmx148mm)

ISBN: 01-872-870-26-0 (216mmx148mm) (210)