Forensic psychology: Part 4: Chapter 13: Assessing offender populations

by Lynn O. Lightfoot, Ph.D. C. Psych. ^{Footnote 1} 

It has been consistently demonstrated in the literature that substance use is highly related to commission of crime, particularly violent crime (Chaiken & Chaiken, 1982,1990; Lightfoot & Hodgins, 1988; Reiss & Roth, 1993; Ross & Lightfoot, 1985; Virkunen, 1974). It has also been well established in the literature that Conduct Disorder in children and Personality Disorder, particularly Antisocial Personality Disorder, predispose persons to the development of substance abuse problems (Elliott & Huzinga, 1984; Cadoret et al., 1985; Cloninger et al., 1989; Schuchit, 1973). As a result, psychologists working in criminal justice settings will frequently need to assess, recommend and, in some cases, provide appropriate treatment to offenders with substance abuse problems. They are also asked to provide recommendations for the management of risk in substance abusing offenders who are being re-integrated into the community.

The goal of this paper is to provide a selective review of the literature relating substance use to crime and to articulate "state of the art" guidelines for the conduct of comprehensive psycho-social assessment, treatment and after-care of substance abuse and related problems in offenders.

Before describing the relationship between substance abuse and offending, it is important to define the terms that will be used throughout this paper. In fact, the problem of definition is one of the fundamental issues in the substance abuse literature. The terms "substance abuse," "dependence" and "addiction" are frequently used interchangeably, without general agreement as to what these terms mean. The difficulty in definition stems, in part, from the different conceptual frameworks which abound in the substance abuse field. In the field of alcoholism, for example, the most widely accepted view (particularly in the U.S.) is the medical model, where alcoholism is conceptualized as a disease (Jellinek, 1952, 1960). Even Jellinek, however, noted that there were a number of different types of alcoholism and only one of these fit with the classic disease model. In recent years, bio-psycho-social models of substance use disorders have led to the development of a variety of multi-dimensional conceptual frameworks (Chaudron & Wilkinson, 1988; Miller & Hester, 1989). There is increasing support for the view that there are multiple alcoholisms with important specific differences in etiology and presentation (Pattison, 1982), which in turn require a range of treatment alternatives.

Some of the "types" of alcoholisms which have been proposed include: essential and reactive (Rudie and McGaughran, 1961), and primary and secondary (Schuckit & Morrissey, 1979). Additionally, Zucker (1987) has identified four different alcoholisms including anti-social, developmentally-limited, developmentally-cumulative and negative affect alcoholism.

Perhaps the most important conceptual development occurred, however, when Edwards and Gross (1976) described the alcohol dependence syndrome. This syndrome consisted of the following essential elements:

• narrowing in the repertoire of drinking behaviour;
• salience of drink-seeking behaviour;
• increased tolerance to alcohol;
• repeated withdrawal symptoms;
• repeated relief or avoidance of withdrawal symptoms by further drinking;
• subjective awareness of the compulsion to drink; and
• reinstatement of the syndrome after abstinence.

All of these elements were seen to exist in degree, giving the syndrome a range of severity. They also specified a variety of alcohol-related disabilities (or problems) which could be experienced without the individual necessarily suffering from the dependence syndrome.

Although not without its critics, the alcohol dependence syndrome has been adopted by both the International Classification of Diseases-9 (ICD-9; World Health Organization, 1979) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSMIII-R; American Psychiatric Association, 1987), the major diagnostic classification systems for mental disorders. In fact, the dependence syndrome forms the conceptual framework for the diagnosis of all psychoactive substance use disorders.

DSMIII-R lists nine specific criteria and specifies that three or more of these must be met to make a diagnosis. The recently released DSM-IV (1994) identifies seven criteria — three or more are required within the same 12 month period for the diagnosis of substance dependence (p. 181), while physiological dependence is independently specified. DSMIII-R also includes an abuse category, which is defined as a pattern of pathological use that causes impairment in social or occupational functioning that lasts for at least a month. A diagnosis of dependence requires, in addition to the above, evidence of tolerance or withdrawal symptoms after use of the substance stops. Four possible courses of the disorder are possible, including: continuous, episodic, in remission, or unspecified. DSM-IV (1994) continues to provide for both substance abuse and/or substance dependence diagnosis. The major difference between DSMIII-R and DSM-IV appears to be that the diagnosis of substance abuse applies when there are recurrent and significant adverse consequences over a twelve month rather than a one month period. A diagnosis of substance abuse continues to exclude tolerance, withdrawal or a pattern of compulsive use, and is restricted to refer only to repeated harmful consequences (i.e., legal problem, impaired work performance, neglect of children/household). DSM-IV provides for six course specifiers, including four remission categories after one month (early full remission, early partial remission, sustained full remission, and sustained partial remission).

In DSMIII-R, this diagnostic model is applied to all drugs and, as a consequence, there are nine different classes of psycho-active substance use disorders:

• alcohol;
• amphetamine or similarly acting sympathomimetic;
• cannabis;
• cocaine;
• hallucinogens;
• inhalants;
• opiates;
• phencyclidine (PCP) or similarly acting arycyclohexlamines; and
• sedative hypnotics or anxiolytics.

DSM-IV includes both nicotine and caffeine, and both DSMIII-R and DSM-IV include a polysubstance diagnostic category.

Although the literature examining the etiology of other forms of psychoactive substance abuse is not as extensive as that for alcohol, there is an increasing awareness of their multi-dimensional nature (Martin & Wilkinson, 1989).

Recently, expert panels in various jurisdictions (i.e., Institute of Medicine, 1990; Ontario Ministry of Health, 1988) have sought to broaden the conceptualization of substance abuse problems to ensure a comprehensive and coordinated approach to substance abuse prevention, early identification, treatment and rehabilitation. As can be seen in Appendix A, the essential conceptual element of this model is that of the "Risk Continuum," which posits that as consumption of a psycho-active substance increases, so does the probability of experiencing health, social, or psychological problems. This model also, however, allows for the emergence of problems related to acute incidents of substance use (i.e., motor vehicle and other accidents, personal injury), and not just to the problems related to chronic high dose patterns of intake. The Risk Continuum model encourages us to consider a range of interventions related to the widely varying risk levels that individuals experience. Under this model, primary prevention activities are aimed at those individuals who are not consuming the substance or who are consuming at very low risk levels. Early intervention (secondary prevention) programs are aimed at those individuals who are just beginning to experience problems related to their substance use, while treatment and rehabilitation programs are directed only toward those individuals who are (by virtue of the quantity and pattern of consumption) at great risk for experiencing serious health, psychological or social problems.

For purposes of clarity, and consistent with the literature described above, throughout this paper we will refer to these two independent aspects of psychoactive substance use: problems (consistent with DSMII-R abuse diagnoses) and dependence (also consistent with DSMII-R dependence diagnoses), which relate to the development of tolerance and physical dependence.

A variety of conceptual models have been proposed to explain the link between substance abuse and crime. Goldstein (1985) has proposed a conceptual framework for understanding the complex relationship between drugs and violent crime which consists of three primary components: psychopharmacological, economic and systemic factors.

Briefly, the psychopharmacological model suggests that some individuals, as a consequence of short or long term use of specific drugs, may become excitable, irrational and may exhibit violent behaviour. The economically-compulsive component of the model, on the other hand, suggests that some drug users engage in economically-oriented violent crime to support costly drug use. The systemic model suggests that violence is intrinsic to illicit drug distribution and to use. In other words, in the drug subculture, violence is a normative behaviour.

The epidemiological literature has consistently found that whether one examines event-based literature (police reports, court records) or interviews with charged or incarcerated offenders, alcohol use is prevalent among perpetrators of violent crimes. Wolfgang (1958) reviewed 588 cases of homicide in Philadelphia over a four-year period and found that alcohol was present in either victim, offender, or both, in 64% of cases. Fifty-eight percent of convicted assaultive offenders were not sober at the time of the offence. Chaiken and Chaiken (1982) reported daily drug use in the month prior to their index offence in 83% of violent offenders. A national survey of incarcerated American offenders reported that onethird of all inmates in state prisons in 1979 had "drunk very heavily" just before committing the offence for which they were convicted (U.S. Bureau of Justice Statistics, 1983). Habitual offenders and persons convicted of assault, burglary and rape were more likely to be very heavy drinkers. Approximately one-third reported being under the influence of an illegal drug at the time they committed the offence for which they were incarcerated. Drug use was most frequently associated with a drug-related offence or burglary, and least often with violent crimes. As noted in the recent report of the Panel on the Understanding and Control of Violent Behaviour (Reiss & Roth, 1993), these types of prevalence data are not conclusive in demonstrating a causal link between alcohol use and violent offences without comparison to the appropriate comparison group (i.e. the proportion of comparable individuals not involved in violence or crime while drinking). Indeed, Greenberg's (1981) review found a high involvement of alcohol use in non-violent as well as violent crime.

There is much less empirical data linking other psychoactive drug use to crime. In the U.S., the Drug Use Forecasting program tests (voluntary) for 10 drugs in arrestees for violent crimes in 22 American cities. Sixty percent of arrestees for violent crimes test positive for at least one drug, with higher rates for public order offences (62%), property and sex offences (66%), and drug offence (83%) (Bureau of Justice Statistics, 1990). It is important to note that multiple drug use is the norm in offender populations, making it virtually impossible to examine differential rates of offending for different drug classes. Psychoactive drug users have generally been found to have higher individual annualized frequencies for robbery and armed robbery offences.

Until recently, there was little in the way of comparative statistical information for incarcerated Canadian offenders. In 1985, Lightfoot and Hodgins (1988) conducted the first systematic anonymous survey of substance abuse problems in a representative sample of 275 incarcerated offenders. Using a variety of standardized measures combined with self-report and interviewer ratings, it was found that almost 70% of inmates reported experiencing at least one alcohol related problem in the six months prior to commission of the index offence. Eighty-seven percent were found to be drinking at levels associated with significant risks to health. However, relatively few offenders were found to be alcohol dependent in this time interval, with 64% of the sample having scores on a measure of alcohol dependence in the "none to moderate" range. With regard to drug use, 80% of inmates reported having used at least one drug in the six month interval prior to the index offence, and 68% reported moderate to severe drug abuse scores on an objective test. As can be seen in Appendix B, the vast majority (79.6%) of surveyed inmates reported substance use on the day of the index offence.

A CSC Task Force report on Mental Health (CSC, 1991) describes the results of a survey of approximately 3,000 Canadian federal offenders. Using the DSMIII-R criteria, the lifetime prevalence rates for alcohol abuse/dependence was 70%, and 53% for (psycho-active) substance dependence. Almost 40% (37.8%) of the sample were dual diagnosis offenders — that is, they met the criteria for anti-social personality disorder and also had an alcohol or drug problem.

The introduction of the Computerized Lifestyle Assessment Instrument (CLAI; Robinson, Porporino & Millson, 1991) to federal institutions and reception centres in Canada has resulted in an ever expanding data base on substance abuse problems in offenders. The CLAI is a modified version of Skinner et al.'s (1985) Computerized Lifestyle Assessment program. Offenders respond to a variety of multiple choice questions about lifestyle practices displayed on a computer screen.

Incorporating substance abuse items in a broader computer-administered lifestyle assessment was intended to increase the validity of self-report data. Aggregation of these data in 1993 (Weekes et. al., 1993) revealed 4,941 cases nationally. As will be discussed later in this paper, although there is likely under-reporting of substance abuse problems by offenders on this self-report instrument, these data provide a benchmark to guide the allocation of resources for early identification, prevention and treatment in federal corrections. The results of this survey indicate that approximately 52% of incarcerated offenders have no evidence of drug-related problems, 20% have low evidence, 12% moderate, 12% substantial and 4% have severe problems. With regard to alcohol dependence, 49% report no alcohol related problems, 35% report low level alcohol related problems, 9% moderate, 5% substantial and 3% severe. Given that the majority of offenders are poly-drug users, combination of the data above reveal 33% with no evidence of a substance abuse problem, 32% with a low substance abuse problem, 16% with a moderate problem, 14% with a substantial problem and 6% with severe substance related problems. An examination of the use of alcohol and drug use on the day of the offence revealed that those with moderate to severe problems were more likely to have used a psycho-active substance on the day of the offence. They were also more likely to have used substances during most of their previous crimes.

A further analysis of some of these data, in which the association between criminal activity and drugs and alcohol use was examined, revealed that drug use was not differentially involved in violent and non-violent offences, while assaultive/injurious and public order offences were most common for frequent or moderately-dependent alcohol users (Millson, Robinson, Porporino & Weekes, 1993). Higher frequencies of drinking and higher levels of dependence were significantly and positively associated with incarceration for violent offences.

Lightfoot and Lambert (1991) conducted a survey of all women federally incarcerated in the Prison for Women, Kingston. Using the same standardized instruments employed in their 1988 survey of male incarcerates, the majority (65%) of women reported some level of drug-related problems: 11.1% low, 18.7% moderate, 21.3% substantial and 13.6% severe. Women were less likely than men to report symptoms of alcohol dependence. The majority (72%) of women reported no symptoms of alcohol dependence, 15% reported moderate dependence, 7.5% substantial dependence and 5% reported severe alcohol dependence. These data contrast with those reported in the CSC Mental Health Task Force Report (1991) where more (39%) female offenders were identified as meeting the criteria for alcohol abuse/dependence, while fewer (22.1%) met the criteria for (psycho-active) substance dependence. These differences in prevalence rates likely reflect the different criteria and methodologies employed in these two studies.

Assessing substance abuse problems in forensic populations presents some very dear challenges to the psychologist. It requires an understanding of both substance abuse assessment and risk assessment in order to develop a comprehensive problem formulation or diagnosis and treatment plan.

Substance abuse as a risk factor in violent recidivism can probably be best conceptualized as falling on a continuum from substance abuse providing "no significant contribution to risk," to substance abuse providing a "very high contribution to risk." Assessment of this risk depends on a number of interacting factors including: nature and extent of substance abuse use, intellectual ability, personality characteristics, peer group, marital status, substance-related disabilities/problems, etc.

Assessment of substance abuse is conducted primarily through use of self-report measures. Most available self-report measures are subject to response biases such as faking/impression management. Although in outpatient treatment settings the self-report of substance abusers has generally been found to be both reliable and valid (O'Farrell & Maisto, 1987), accurate self-report is usually only available where confidentiality can be assured and there is no strong motivation to avoid detection (Sobell, Sobell & Nirenberg, 1988). This is clearly not the case for offenders entering the criminal justice system. The prison grapevine in Canada, for example, informs newcomers about the fact that there is a computerized assessment for substance abuse problems, and that if you are truthful in describing your pattern of use that you could literally be there for hours. In addition, newcomers are informed that if they are identified as having a problem, not only will they be required to undergo treatment before being considered for parole, but they will also have a parole condition to abstain from all substances.

It might be argued that the most serious error in assessment is the false negative. This is the offender who denies acute or chronic substance use/abuse on self-report indices, but where substance use/abuse has in fact been a risk factor in past offences. Here, the failure to identify treatment needs and substance abuse as a risk factor to be managed in release planning and community supervision, may result in increased risk to the community. An example of this type of error is the offender who, in completing initial screening (i.e., the Computerized Lifestyle Assessment), consistently reports low levels of use of all substances, and none or few problems related to substance use. This offender would likely be seen as requiring little if any formal treatment to address substance abuse. However, careful review of the file reveals a series of convictions for driving under the influence, driving while impaired, and previous assault charges in which the offender is described as being under the influence. In this situation, the offender may either be minimizing to avoid detection, or his defense mechanism (denial) is so effective he may not have identified the relationship of his legal problems to his drinking behaviour.

False positive errors are also problematic. In this situation, substance abuse is identified as a risk factor based on little or no empirical information, or where the offender claims substance abuse problems during prosecution only to lessen criminal responsibility. In this instance, costly treatment resources may be used when, in fact, substance abuse as a risk factor for criminal recidivism is minimal.

In order to increase the validity and reliability of substance abuse/dependence assessments, it is generally recommended that this be achieved through a process of "convergent validity" (Sobell & Sobell, 1980). In other words, a variety of indicators, including the interview, and reliable and valid standardized tests should be used and combined with information from official documents/reports and collateral informants before making a judgment, so that the validity of the assessment is maximized. Appendix C provides a checklist of the range of measures which should be included in a comprehensive substance abuse assessment.

This should be combined with some kind of actuarial measure of risk such as the Hare Psychopathy Checklist — Revised (Hare, 1991), or the Statistical Risk Appraisal Guide (Harris, Rice & Quinsey, 1993), or the Statistical Indicator of Risk (SIR; Nuffield, 1982) in order to provide a comprehensive assessment of risk.

It has been widely recognized that substance abuse assessment should encompass a variety of life areas likely to be affected by substance abuse (i.e., social, employment, health). Improvement in functioning in these life areas does not necessarily follow from successful treatment, even wh.en continuous abstinence is achieved (Pattison, Sobell & Sobell, 1977). Untreated, concomitant problems can also result in relapse (Miller & Hester, 1989; Marlatt & Gordon, 1985). As a result, systems of assessment have been developed to address a wide variety of life areas. Examples are the Comprehensive Drinker Profile (Miller & Marlatt, 1984) and the Structured Addictions Assessment Interview for Selecting Treatment (Addiction Research Foundation, 1984). This latter instrument has been revised for offenders, (Hodgins & Lightfoot, 1989; Lightfoot & Hodgins, 1988).

Substance abusers who are also diagnosed with another mental disorder have been found to have poorer outcomes than those without a dual diagnosis (McLellan et al., 1983a; Rouansville et al., 1986). Comprehensive substance abuse assessment must, therefore, address concomitant psychopathology. Commonly used comprehensive personality assessment tools like the MMPI-II (Butcher et al., 1989), the Millon, or a brief screening device such as the General Health Questionnaire (Goldberg & Hillier, 1979), can be used to assess the degree and nature of psychopathology.

Cognitive impairment and memory deficits are common sequelae of substance abuse (Miller & Saucedo, 1985; Parsons, Butters, & Nathan, 1987; Wilkinson & Carlen, 1981). As Larldn (1994) has recently pointed out, severe cognitive deficits such as Wernicke-Korsakoff Syndrome, are relatively rare in the alcohol abusing population, but less severe cognitive impairment can be found in up to 75% of an alcohol abusing population. These deficits include visio-spatial, visio-motor, learning, memory, and abstract reasoning abilities. Because vocabulary and verbal skills are the least affected, cognitive impairment is not easily determined from casual conversation or in clinical interviews. Cognitive impairment may result in behaviour which can be mistaken for other psychological problems (i.e., personality disorder, denial). Comprehensive assessment and treatment planning for substance abusers, therefore, is not possible without an assessment of the cognitive abilities which are known to be adversely affected by alcohol. Two tests have been found to be particularly sensitive to these deficits: the Trails test from the Halstead Reitan test battery (Reitan, 1958), and the Digit Symbol subtest from the WAIS-R (Wechsler, 1981). Currently, research efforts are being directed toward developing a greater understanding of the cognitive recovery process, and treatment techniques originally designed for head trauma and stroke patients are being tested with alcohol populations (Gordon, Kennedy .S.1. McPeake, 1988). Little research has addressed the neuro-psychological effects of drugs other than alcohol.

It has been broadly recognized that the heterogeneity of alcohol and drug problems requires a number of different treatment alternatives. Miller & Hester (1986) have demonstrated how the different etiological models indicate different approaches to treatment. For example, proponents of biological models which emphasize the role of genetic and bio-physiological factors, search for chemotherapeutic interventions; those models advocating social learning factors, which emphasize the relationship between the individual (coping skills, cognitive processes) and the environment (modelling by family and peers), intervene by altering the individual's relationship to his or her environment.

Sociocultural models, which emphasize the impact of social and cultural influences on substance use, intervene at a "systems" or societal level by reducing the availability of substances through taxation, advertising, and interdiction.

Treatment itself can be broken down into a series of phases which include (Ross & Lightfoot, 1985; Institute of Medicine, 1990):

1. case identification;
2. detoxification;
3. assessment;
4. treatment; and
5. aftercare

The first phase of treatment following case identification and detoxification provides for safe withdrawal from the substance and may be medical or nonmedical in nature.

Detoxification itself, however, infrequently leads to long term behaviour change, and is usually seen only as the first stage of the formal treatment process.

The second phase of the process, active treatment, tries to reduce or eliminate substance abuse and associated problems. There is an extensive array of treatment interventions for substance abuse, and a comprehensive review of the voluminous treatment outcome literature for alcohol and other drugs is beyond the scope of this paper.

For more in depth description of the various therapeutic modalities and the methodological issues involved in program evaluation, the interested reader is referred to a number of excellent sources (for alcohol see Miller & Hester, 1986; Institute of Medicine, 1990; for other drugs see Wish & Johnson, 1986; for program evaluation, see Lightfoot & Boland, 1994).

A brief descriptive overview of the major modalities for substance abuse treatment is provided below. It should be noted that few of the outcome studies described below specifically address offender populations.

When offenders are specifically studied, they are usually DWI (driving while intoxicated) offenders, and thus do not represent the population of offenders seen in federal correctional facilities.

Pharmacotherapy, or drug treatment, consists of three types of intervention. Antidipsotropic drugs interfere with the normal metabolism of drugs and, as a result, can cause adverse physical symptoms when the substance is used. The patient is administered the drug and advised of the aversive symptom sequelae in an attempt to suppress use. Antabuse (disulfiram) and Temposil (citrate calcium carbamide) are the primary substances used to deter alcohol use. Outcome studies tend to indicate that antidipsotropic drugs on their own are ineffective in the long term reduction of alcohol use (Fuller et al., 1986; Ling et al., 1983; Powell et al., 1986). They may, however, be effective adjuncts to treatment if a motivational intervention to increase compliance is added to the treatment program (Azrin et al., 1982).

The second class of drugs used in the treatment of substance abuse disorders are those which block the mood enhancing effects of the drug. Serotonin uptake inhibitors (i.e., zimelidine, citropram, fluoxetine, fluvoxamine) appear to block the euphoriant effects of alcohol, reduce the desire to drink, and increase the number of abstinent days for heavy drinkers (Amit et al., 1985; Naranjo et al., 1984). Opiate antagonists (naloxone) are used in the treatment of opiate addiction by displacing the opiate drug molecules from their receptor sites, thus precipitating withdrawal from the drug. Methadone is a synthetic narcotic drug that is administered in specialized methadone maintenance or abstinence-oriented treatment programs. It does not produce the same degree of euphoria as heroin, but because it is medically prescribed it does provide the severely dependent user with a legal alternative to heroin use. Methadone treatment programs have consistently been found to reduce the rate of drug use and offending in heroin-addicted offenders (Ball, Shaffer & Nurco, 1983; Gerstein & Harwood, 1990).

Another major use of psychotropic medications is for the reduction of the severity of withdrawal symptoms during detoxification (Liskow & Goodwin,1987). Psychotropic drugs are also used to treat concomitant psychiatric disorders in dual diagnosis individuals. Untreated psychiatric disorder is associated with poor prognosis and high treatment dropout rates among substance abusers (Rounsaville et al., 1986; Kofoed et al., 1986; McLellan et al., 1983). In conclusion, it would appear that, at present, the use of psychotropic medications are viewed as adjuncts to treatment for substance abuse rather than as a primary intervention. Because there are few drugs available to block drug cravings produced by other illicit drugs, future research will, therefore, likely target the development of drugs which block dopamine and norepinephrine receptors (Reiss & Roth, 1993).

Aversion treatment is based on a counter conditioning model in which an aversive stimuli, like electric shock or an emetic drug, is repeatedly paired with the abused substance in order to create a conditioned aversive response to that substance. Although not widely employed in North America, and strongly criticized by some (i.e., Wilson, 1987), chemical aversion studies have demonstrated a conditioned aversive response to alcohol, the strength of which is predictive of treatment outcome (Cannon & Baker, 1981; Cannon et al., 1986).

Covert sensitization, which uses imagery as the aversive stimulus in the counterconditioning paradigm, produces a conditioned aversion to alcohol, the strength of which is similarly predictive of outcome (Miller & Dougher, 1984).

Although a standard element of many treatment programs, reviews of the literature (Miller & Hester, 1986a; Institute of Medicine, 1990) have consistently found that there is little evidence supporting the use of didactic (preachy) educational lectures as an effective treatment modal for substance abusers. However, research to date has not addressed the extent to which different adult learning technologies may increase the effectiveness of educational interventions, or to what extent educational units contribute to program effectiveness in multi-modal treatment programs.

Alcoholics Anonymous (AA), Narcotics Anonymous, Al-Anon, and Adult Children of Alcoholics are all self-help or mutual aid groups. From a cost-effectiveness perspective, these programs have a number of distinct advantages. Population surveys have shown that they are the most widely known (Health & Welfare Canada, 1990), are almost universally available, and provide free services for substance abusers and their families throughout North America. Because of their anonymous nature, however, there has been very little controlled outcome research which addresses the efficacy of these interventions. Only three controlled studies have examined outcomes and none has demonstrated a significant effect of AA attendance. Brandsma, Maultsby and Welsh (1980) randomly assigned court-mandated problem drinkers to either AA or to no treatment, and found no long term differences in outcome. Correctional studies have found higher abstinence rates in regular AA attendees (Polich, Armor & Braiker, 1980; Hoffman, Harrison & Belille, 1983), but treatment compliance confuses the interpretation of these types of studies. Research has also consistently shown that relapses, when they occur, are more severe in AA participants (Glaser & Ogborne, 1977). In a recent review of AA, McCrady & Irvine (1989) conclude that although AA may be an important element of treatment for some individuals, "the data do not support the widespread belief that AA is the most effective treatment for alcoholism" (p. 168).

In general, insight oriented, or psycho-dynamic psychotherapy have not demonstrated a significant impact on drinking outcome. Confrontational therapy has been found to produce either no effect (Swenson & Clay, 1980) or negative effects (Annis & Chan, 1983). There is some evidence that cognitive behavioural therapy improves outcomes in alcohol abusers (Oei & Jackson, 1982, 1984), but the evidence is mixed (Sanchez-Craig & Walker, 1982).

BSCT involves teaching substance abusers a set of strategies for modifying drinking behaviour. This usually includes goal setting, blood alcohol concentration training, self-monitoring, rate control training, self-reinforcement training, functional analysis of drinking, and training in alternative coping skills. These skills can be used to achieve moderation or abstinence goals. BSCT has been subjected to a great deal of research. This research has found BSCT to be more effective than education, no treatment, or an AA-based therapy group (Miller, Taylor & West, 1980; Sanchez-Craig, 1984: Stimmel et al., 1983).

Broad spectrum treatment programs include a variety of interventions designed to address concomitant problems or skill deficits which are thought to be functionally related to substance abuse. The Community Reinforcement program (Azrin, 1976; Hunt & Azrin, 1973) teaches a variety of coping skills and includes: problem-solving, behavioural family therapy job finding club, social skills training, supervised Antabuse, and a "buddy system." This program was particularly effective for unmarried clients, but outcomes were vastly superior to a control group consisting of a standard hospital program.

Social skills training has frequently been found to be an effective intervention with substance abusers (Chick et al., 1988; Erikson, Bjornstad & Gotestam, 1986; Ferrell & Galassi, 1981; Jones, Kanfer & Lanyon, 1982). Stress management training has also been found to be an effective intervention, particularly for those with high levels of anxiety (Miller & Hester, 1986).

Therapeutic communities have most frequently been used in the treatment of heroin addicts, but recently have been modified to address the needs of cocaine abusers. These programs typically involve a highly structured residential program which lasts several months with highly confrontational group therapy, resocialization, progressive responsibility and gradual reentry into the community.

It has been very difficult to conduct randomized experiments with these programs, but the results of the best designed outcome studies indicate that some forms of therapeutic community significantly reduce relapse rates and criminal activity in some offenders (Institute of Medicine, 1990). Gerstein and Harwood (1990) suggest that a minimum of three months of program involvement is required to achieve these reductions. They also conclude that several other programs such as Stay'n Out (New York), Cornerstone (Oregon State Hospital), and the California Civil Addict Program, which begin treatment in the institution and follow-up with aftercare in the community, have demonstrated significantly reduced re-arrest rates for offenders who completed these programs.

In recent years, following the pioneering work of Marlatt and associates (Marlatt & Gordon, 1985), relapse to substance use has increasingly been viewed as a process, rather than a discrete event. Relapse prevention is a set of treatment procedures which identify antecedents to substance abuse as high risk situations, and assists the client to identify alternative coping strategies for dealing with these situations. Relapse prevention has been used as a component of treatment and as a specific intervention. Unfortunately, results to date have proved disappointing. Annis et al. (1988) found only a modest effect on outcome, while others have found no difference between relapse prevention and other control or standard interventions (Ito, Donovan & Hall, 1988; Rosenberg & Brain, 1986).

In general, expert reviews of the efficacy of substance abuse treatment have concluded that there is no single treatment approach which is effective for all persons with substance related abuse/dependence (Institute of Medicine, 1990). For unselected substance abusers, controlled studies comparing high to low intensity treatment (i.e., outpatient counselling vs. residential treatment) have consistently found no significant overall differences in effectiveness. However, there is some evidence that intensive treatment is more effective for the individuals with more severe substance abuse problems (i.e. more problems, higher level of dependence) and who are less socially stable (McLellan, Luborsky, Woody, O'Brien & Druley, 1983; Orford, Oppenheimer & Edwards 1976).

Given the heterogeneity of substance abusers, the fact that major reviews of treatment outcome literature for alcohol and other drugs (Gendreau and Ross, 1982; Ross & Lightfoot, 1985; Institute of Medicine, 1990; Miller & Hester, 1986) have failed to identify any single "magic bullet" is not surprising. Rather, there are many types of alcohol and drug dependent individuals requiring a spectrum of therapies appropriate to their particular needs. Research is accumulating which suggests that treatment efficacy is enhanced by matching individuals to treatment on the basis of social, demographic, personality, or cognitive variables (Annis & Chan, 1988; Hodgins, 1986; Miller, 1989).

Annis and Chan (1983), in a study of 150 incarcerated substance abusing offenders, found that an intensive confrontative group therapy program was effective in reducing recidivism in offenders with a positive self-image. However, offenders with a negative self-image had more re-convictions and committed more severe offences after receiving group therapy than when they received regular institutional care. This study shows that indiscriminately applied treatments may not only be ineffective, but may produce negative effects on participants.

Lightfoot and associates (Hodgins & Lightfoot, 1988; Lightfoot & Hodgins, 1993) have attempted to empirically develop a typology of substance abusing offenders. The purpose of trying to identify offender types is to facilitate the development of treatment programs that are "tailor-made" to address the specific needs of the different offender types. Hodgins and Lightfoot (1988) surveyed the literature to identify all potentially significant matching variables. Using cluster analysis, they were able to identity four "types" of offenders. One of the primary underlying dimensions of the typology was that of substance problem severity; the other was problem substance type. Thus, some offenders reported problems primarily with alcohol, while others reported primarily illicit drug problems. Appendix D provides a brief overview of each of the offender types and the type of treatment which is suggested based on the characteristics of that type. The four types include a Drug Abuser Group, an Alcohol Abuser Group, an Emotionally Distressed Poly-Drug Abuser Group and an Organically Impaired Alcohol & Drug Dependent Group. It is important to note that two variables, psychopathology and cognitive impairment, which have been consistently identified as important predictor and matching variables from the outcome literature, were identified with the offender sample as also highly important potential matching variables. Lightfoot and Hodgins (1993) have described how treatment for these four types could be matched to offender needs through the development and integration of treatment elements which address the special needs and skill deficits which each of the types presents. Development of this typology has led to the development of the Offender Substance Abuse Pre-release Program (OSAPP) [Lightfoot, 1989; 1993(a)(b)].

Because offenders present unique patterns of strengths and deficits, rather than simply looking at group change scores, we (Barker, 1990; Lightfoot & Barker, 1989; Lightfoot, 1993) developed a methodology for examining the pattern of significant pre-post changes in individual participants, before aggregating and analyzing the change score data. Results of the preliminary evaluations demonstrated that most program participants increased significantly on 2 or more of the post-test measures. A 15 month follow-up study of 324 OSAPP treated offenders (Weekes, Millson, Porporino & Robinson, 1994) found that most demonstrated significant improvements on most of the pre-post test measures. Over 90% of offenders who completed the program were released, of those, 30.25% were readmitted into custody within the 15 month follow-up period. Rates of readmission varied directly as a function of substance abuse severity level. Offenders demonstrating moderate to severe substance abuse problems were much more likely to be readmitted than those with low problem severities. In addition, readmission rates were also directly related to the number of pre-post measures on which offenders demonstrated improvement. For example, only 19% of offenders who improved on pre-post test measures reoffended, while 36% of those who showed no improvement were readmitted. These findings were also confirmed in a survival analysis.

One of the most controversial areas in the substance abuse field in recent years has been the topic of goal selection [Miller, 1986; Peele, 1984, 1987; Wallace, 1987(a)(b)], particularly in the treatment of alcohol abuse/dependence (Sanchez-Craig & Lei, 1987), but also in relationship to the treatment of other drug dependence disorders (Martin & Wilkinson, 1989), and to the specific treatment of alcohol abusing offenders (Ross & Lightfoot, 1985).

The controversy appears to stem largely from those supporting traditional programs (i.e., disease model). These traditionalists are opposed to recent research which has indicated that controlled drinking or moderation is a feasible goal for some substance abusers. Traditionalists hold that substance abuse disorders are progressive diseases, and that effective treatment requires a commitment to lifelong complete abstinence (Stockwel1,1986).

Research, on the other hand, demonstrates that particularly for young single males, moderation goals are more likely to be complied with and, therefore, are more successful than abstinence goals (Sanchez-Craig et al., 1984; Sanchez-Craig & Lei, 1986). Controlled drinking is usually defined as including some limit on the amount and frequency of consumption, and drinking which does not result in signs of physical dependence or social, legal, or health problems (Heather & Tebbut, 1989).

In a recent review of the literature, Rosenberg (1993) concluded that controlled drinking outcomes are as frequent as abstinence outcomes in many populations. Sanchez-Craig and Wilkinson (1993) have recently reviewed the contraindications to moderate drinking goals and these include: health status, legal status, and personal preferences and beliefs. Others have suggested that degree of dependence is also an important consideration (Miller & Hester, 1986; Rosenberg, 1993), while post-treatment characteristics have recently been identified as important in predicting controlled drinking (CD) outcomes.

The parole board, before releasing an offender back into the community, will usually include a condition of abstinence if that offender was identified with a substance abuse problem. This will often be accompanied by urinalysis at the discretion of the parole officer to monitor compliance. Because of the limitations of urinalysis, particularly for detecting alcohol use, many offenders engage in some substance use upon release.

Treatment should therefore include a careful analysis of the choice to use, including a detailed listing of the risks and benefits of use. Reframing the abstinence parole condition in positive terms (i.e., providing an opportunity to learn and practice new coping skills) rather than as unwanted and unwarranted control, and encouragement to strive for abstinence at least until warrant expiry are effective intervention strategies with some offenders.

As summarized succinctly by Rosenberg (1993), "predicting the likelihood that an individual will drink moderately or abstain is probably best conducted in the context of a therapeutic relationship in which multiple patient characteristics are considered, support and training for the client's goal choice are provided, and post-treatment circumstances and consumption are monitored to permit intervention if drinking becomes uncontrolled" (p. 135).

i) Compulsory treatment
One of the major questions frequently encountered in the substance abuse field is whether compulsory treatment works. The traditional wisdom has always held that the substance abuser must accept his "illness" and be willing to seek treatment or it will not be effective. On the other hand, it is also widely acknowledged that most individuals seeking treatment do so because someone - an employer, a partner, a parent - is exerting some kind of pressure.

The empirical literature is rather scanty, but the few available studies do tend to indicate that: a) involuntary clients do as well as voluntary clients; and b) offenders who are treated have lower recidivism rates than untreated offenders (Fagan & Fagan, 1982; New York State Governor's Task Force on Alcoholism Treatment in Criminal Justice, 1986).

ii) Aftercare
Although the active or intensive phase of substance abuse treatment is often considered as the key to achieving a successful outcome, research has consistently shown that post-treatment factors are as highly related to outcome as are pre-treatment and treatment (Conkrite & Moos, 1980; Finney, Moos & Newborn, 1980). Post-treatment factors include life stressors, coping strategies, and social resources. For treatment to be effective, ideally it should extend beyond the active phase to the context in which the patient will be functioning after treatment. For this reason, many programs offer aftercare programs which involve ongoing contact with the client for an extended period of time following the completion of the active phase of treatment. In general, there appears to be a positive correlation between aftercare attendance and sustained remission (Ito & Donovan, 1986; Ornstein & Cherepon, 1985). Some experimental evidence suggests that a behavioural contracting intervention significantly increased aftercare attendance and outcome, compared to controls. Other studies have failed to demonstrate these kinds of effects (i.e., Fitzgerald & Mulford, 1985). McLachlan's research (1972, 1974), however, suggests that there may be a need to match specific aftercare approaches to the characteristics of the participant.

Lightfoot & Boland (1993) recently developed a brief treatment and relapse prevention program, "CHOICES," for Canadian offenders, which provides an intense but brief intervention (7 hours a day for 5 days) as soon as possible after release to the community. Participants are then expected to attend weekly maintenance sessions for a minimum of three months. Preliminary evaluation results suggest that retention is excellent and recidivism rates are comparable to those seen in more intensive treatment.

Substance abuse and dependence are highly complex problems which are highly prevalent within criminal justice populations. Anti-social behaviour and substance abuse are highly associated, and may have some common etiological roots. In this chapter, we have attempted to review the literature addressing substance abuse assessment and treatment, and to derive from this review, state-of-the-art practice guidelines for psychologists working in correctional settings.

In 1992, the Correctional Service of Canada introduced a framework for the identification and treatment of substance abuse. This model, depicted in Appendix E, consists of five components which are designed to address the offender's needs from entry into the system until warrant expiry. Identification of a substance abuse problem is made using the Computerized Lifestyle Assessment Instrument as part of a comprehensive front-end assessment. An alcohol and drug education induction module is provided to all new offenders, after which they are expected to participate collaboratively with their case manager in the identification of the most appropriate treatment based on their risks and needs. Follow-up and support are then provided after the completion of treatment in both the institution and the community.

Through the provision of specialized and comprehensive assessment, treatment and consultation services to case managers, parole officers and supervisors, and to treatment program staff, correctional psychologists can play an important role in enhancing the quality of the continuum of services provided to substance abusing offenders.

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