عوامل سرویس گیرنده و برنامه ای مرتبط با ترک تحصیل از درمان مواد مخدر موظفی از دادگاه

To examine why court mandated offenders dropout of drug treatment and to compare their characteristics, treatment experiences, perceptions, and outcomes with treatment completers, we analyzed self-reported and administrative data on 542 dropouts (59%) and 384 completers (41%) assessed for Proposition 36 treatment by thirty sites in five California counties during 2004. At intake, dropouts had lengthier criminal histories, lower treatment motivation, more severe employment and psychiatric problems, and more were using drugs, especially heroin. Relatively fewer dropouts received residential treatment and their retention was much shorter. A similar proportion of dropouts received services as completers and the mean number of services received per day by dropouts was generally more, especially to address psychiatric problems, during the first three months of treatment. The most commonly offender-reported reasons for dropout included low treatment motivation (46.2%) and the difficulty of the Proposition 36 program (20.0%). Consequences for dropout included incarceration (25.3%) and permission to try treatment again (24.0%). Several factors predicting drug treatment dropout were identified. Both groups demonstrated improved functioning at one-year follow-up, but fewer dropouts had a successful outcome (34.5% vs. 59.1%) and their recidivism rate was significantly higher (62.9% vs. 28.9%) even after controlling for baseline differences. Understanding factors associated with drug treatment dropout can aid efforts to improve completion rates, outcomes, and overall effectiveness of California's Proposition 36 program. Findings may also aid a broader audience of researchers and policy analysts who are charged with designing and evaluating criminal-justice diversion programs for treating drug-addicted offenders.

California's voter-initiated Proposition 36 (Prop 36) has been referring approximately 50,000 drug offenders to community-based drug treatment each year since its inception in 2001. The Prop 36 program was intended to preserve jail and prison cells for serious and violent offenders; enhance public safety by reducing drug-related crime; and improve public health by reducing drug abuse through proven and effective treatment strategies (California Department of Alcohol & Drug Programs, 2008). One notable success of Prop 36 implementation is that about 70% of offenders who agree to enter treatment go on to do so. However, Prop 36 program participation rates drop off dramatically thereafter, with only about 32% of offenders who enter treatment actually completing it (UCLA ISAP, 2006). Completion of treatment is a significant milestone with legal implications under Prop 36. Participants who successfully complete the Prop 36 program can have expunged the criminal arrest and conviction that made them eligible for the Prop 36 program. Also, the program legally entitles offenders up to three chances to succeed in treatment. Depending on the number of chances an offender has utilized, not completing treatment can be counted as a violation of the conditions of the Prop 36 program, making an offender either eligible for additional treatment opportunities or subject to immediate criminal justice sanctions. In addition to the legal aspects of completing treatment, statewide Prop 36 evaluation reports have provided evidence demonstrating that treatment completion is related to improved offender functioning in multiple domains over time. Compared to non-completers, treatment completers had significantly lower re-arrest and conviction rates and savings per offender were more than twice as high over a 30-month follow-up period (UCLA ISAP, 2006). Completion rates by county have also been documented, with rates remaining between 20% and 50% in most counties (UCLA ISAP, 2006). Other research has examined differences in treatment status by Prop 36 offender characteristics and these analyses showed completion rates to be lower for African-Americans and Hispanics (vs. other race/ethnicities), parolees (vs. probationers), and heroin users (vs. users of other drug types) (UCLA ISAP, 2006). In contrast to the large amount of research conducted on drug treatment completion and retention generally, very little research has been conducted on Prop 36 treatment completion. The work that has been done has been useful for stimulating dialogue on whether to continue funding for the Prop 36 program (Little Hoover Commission, 2008). However a noticeable omission is that very little information has been made available on the much larger proportion (approximately 68%) of Prop 36 offenders who enter treatment but do not complete it, that is, the Prop 36 drug treatment dropouts. The existing literature has identified a number of client-level characteristics associated with drug treatment dropout. Although studies indicate that some individuals may leave treatment early due to greater resources and higher levels of functioning (Meier, Donmall, McElduff, Barrowclough, & Heller, 2006), typically problems among treatment dropouts are more severe when compared with those of completers, and those problems have been shown to cut across multiple areas of functioning such as socio-economic status, mental health, drug use patterns, criminal history, motivation level, and personal and social relationships. For example, drug treatment dropout has been associated with less education (Butzin, Saum, & Scarpitti, 2002; Knight, Logan, & Simpson, 2001), unemployment (Butzin et al., 2002; Choi & Ryan, 2006), younger age (Choi & Ryan, 2006; Sinha, Easton, & Kemp, 2003; Siqueland et al., 1998), African-American race (King & Canada, 2004; Scott-Lennox, Rose, Bohlig, & Lennox, 2000), co-occurring psychiatric diagnoses (Amodeo, Chassler, Oettinger, Labiosa, & Lundgren, 2008; Siqueland et al., 1998), more frequent or recent drug use (Amodeo et al., 2008; Butzin et al., 2002), primary use of drugs other than alcohol (Callaghan, 2003) (particularly heroin [Choi & Ryan, 2006] or cocaine [King & Canada, 2004; Siqueland et al., 1998]), low motivation for treatment (Callaghan et al., 2005), a greater number of recent arrests (Knight et al., 2001), cognitive deficits (McKellar, Kelly, Harris, & Moos, 2006), a history of childhood abuse or neglect (Kang, Deren, & Goldstein, 2002), caring for dependent children (Scott-Lennox et al., 2000), poorer family and social functioning (Sayre et al., 2002), peer deviance (Knight et al., 2001), and living situation (Amodeo et al., 2008). Other literature has highlighted the influence of criminal justice status on drug treatment continuation and dropout (Beynon, Bellis, & McVeigh, 2006; Daughters et al., 2008; Harrison et al., 2007; Perron & Bright, 2008). A few studies have focused attention on other aspects of drug treatment dropout such as client perspectives on dropout (Ball, Carroll, Canning-Ball, & Rounsaville, 2006), treatment program factors associated with dropout (Beardsley, Wish, Fitzelle, O’Grady, & Arria, 2003; Harrison et al., 2007; Helmus, Downey, Arfken, Henderson, & Schuster, 2001; Marrero et al., 2005; McKellar et al., 2006; Meier & Best, 2006; Meier et al., 2006), and characteristics of individuals who dropout within the first 30 days after admission (De Weert-Van Oene, Schippers, De Jong, & Schrijvers, 2001). Across studies, the definition of treatment dropout and completion may vary. Some studies have utilized official records on status at exit from care as documented by treatment staff (Beardsley et al., 2003; Bell, Burrell, Indig, & Gilmour, 2006; Beynon et al., 2006; Callaghan, 2003; Choi & Ryan, 2006; Knight et al., 2001; McKellar et al., 2006; Perron & Bright, 2008; Scott-Lennox et al., 2000). However, given that information on discharge status may be missing, many clients enter care repeatedly within a short timeframe, and determination of status may vary by treatment staff or site, others have analyzed retention or service utilization measures to construct indicators of treatment engagement, non-compliance, completion or dropout (King & Canada, 2004; Meier et al., 2006; Sayre et al., 2002; Siqueland et al., 1998), or relied on self-reported measures of treatment discharge status (Marrero et al., 2005). As for Prop 36, the only information that is available on treatment dropouts is provided within a cost-benefit framework and is primarily focused on recidivism (UCLA ISAP, 2006). No other information has been provided to answer basic questions regarding this significant sub-group. Who are the Prop 36 treatment dropouts, what are their reasons for not completing treatment, and what happens to these individuals over time? This article focuses on individuals who enter but dropout of Proposition 36 drug treatment before completing it. Utilizing self-reported and official indicators of treatment dropout and completion, we address the following research questions: (1) how do Proposition 36 treatment dropouts differ from completers in characteristics, problem severity, criminal history, and motivation level at assessment for treatment? (2) are there differences in the type and amount of treatment services that are received by dropouts compared to completers? (3) what reasons do Proposition 36 offenders give for dropping out of treatment? (4) what are the criminal justice consequences associated with not completing treatment as reported by Proposition 36 treatment dropouts? (5) what are the predictors of treatment dropout? (6) do outcomes (drug use, recidivism, incarceration, employment) differ between the two groups? We hypothesized that compared to treatment completers, Prop 36 treatment dropouts would be more criminally severe, have a more severe substance abuse problem, and demonstrate a lower treatment motivation level at intake. We also expected that dropouts would have a much shorter stay in treatment and that they would receive very few services. We expected predictors of dropout to be congruent with the literature on drug treatment dropout. Also, we expected offender reasons for dropout to vary, but because the Prop 36 program provides offenders with several opportunities to successfully complete treatment, we expected that the primary consequence for dropout would be a return to treatment. Finally, we expected dropouts to have poorer outcomes (higher rates of re-arrest, drug use, incarceration, and unemployment at follow-up) than treatment completers one year after entry into the Prop 36 program. Prop 36 has introduced many new drug offenders to treatment for the very first time (Hser et al., 2007; Longshore et al., 2004; Longshore et al., 2005) but approximately 68% of offenders who are eligible for treatment actually enter care and only 32% complete it. The broader implication of these two statistics is that less than one-quarter of eligible drug offenders actually take full advantage of the opportunity for treatment that is offered by the Prop 36 program. This issue of treatment as a missed opportunity could seriously jeopardize the effectiveness of Prop 36 as a criminal justice diversion option in California, and it highlights the need to identify strategies for improving both policies and programming that guide the Prop 36 program (Little Hoover Commission, 2008). Issues related to the problem of treatment no-shows have been examined elsewhere (Evans et al., 2008). Increased understanding of barriers to treatment completion as well as offender attitudes and experiences of treatment dropout are needed to help stakeholders make appropriate modifications to improve the effectiveness of the Prop 36 program.