Substance Use & Misuse, 49:836–841, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.880722
ORIGINAL ARTICLE
Anxiety and Suicidal Ideation Predict Successful Completion of Substance Abuse Treatment in a Criminal Justice Sample C. Brendan Clark, Peter S. Hendricks, Ashley Brown and Karen L. Cropsey University of Alabama at Birmingham, Birmingham, USA dential treatment, and there are modalities available both for incarcerated individuals and those being supervised in the community. Tailoring treatment to the unique needs of members of the criminal justice system remains a critical necessity (NIDA, 2006), especially as the number of people in the criminal justice system continues to grow. Although the efficacy of treatment has been established, there has been very little research examining the client characteristics associated with success in the criminal justice system. The identification of characteristics linked to success at different levels of care, and the subsequent matching of client need to corresponding treatment, is an important step in not only reducing the cost of treatment for offenders but also of increasing the efficacy of the system, identifying the best timing for interventions, and reducing clinician burnout. Treatment completion has often been used a proxy of treatment success and efficacy (Butzin, Saum, & Scarpitti, 2002; Evans, Li, & Hser, 2009; MateyokeScrivner, Webster, Staton, & Leukefeld, 2004; Roll, Prendergast, Richardson, Burdon, & Ramirez, 2005), because completing treatment demonstrates stability and often requires maintaining negative urine drug screens (UDS) as well as staying out of legal trouble. The literature has identified a number of specific characteristics associated with treatment completion in the criminal justice population including steady employment and higher education (Brown, 2010, Butzin et al., 2002; Roll et al., 2005). However, members of the criminal justice system are typically faced with numerous barriers to treatment (i.e., lack of health insurance, unreliable transportation, unemployment, and unstable living situation), which may explain why economic stability appears to be a more salient predictor of outcome in this specific population than in more affluent ones (Sung, Mahoney, & Mellow, 2010; Taxman, 1998). Similarly, individuals on probation (sentenced to serve time under supervision in the community rather than incarceration) tend to do better than those on parole (sentenced to community supervision after incarceration),
The goal of this study was to identify predictors of successful substance abuse treatment in an out-patient clinic for individuals being monitored under community corrections supervision. Of the 615 participants, 117 (19%) successfully completed treatment. The results of a multivariate logistic regression analysis indicated that successful treatment was associated with several baseline characteristics including: older age, White race, having greater than a high school education, lower level of care, meeting criteria for an anxiety disorder, reporting suicidal ideation, and not having a history of opioid use. The value of self-report of problems and its influence on treatment in the culture of the criminal justice population is discussed in this article. Keywords criminal justice, community corrections, treatment completion, anxiety, suicidal ideation
INTRODUCTION
Approximately 50% of individuals in the criminal justice system meet criteria for a substance use disorder (SUD; ref. Bureau of Justice Statistics, BJS, 2006a; Kubiak, Arfken, Swartz, & Koch, 2006). Although the persistence of SUDs is associated with increased rates of recidivism (Walter et al., 2011), treating these disorders reduces repeated criminal behavior, benefiting both the criminal justice population and society as a whole (Peters & Murrin, 2000). Although punitive sanctions are ineffective at reducing drug use, SUD treatment has repeatedly been shown to benefit substance users in the criminal justice system (Chandler, Fletcher, & Volkow 2009; Fielding, Tye, Ogawa, Imam, & Long, 2002), with the cost of treatment approximately five times less expensive than incarceration (National Institute of Drug Abuse, 2006; TASC.org, 2011). Despite the tremendous progress made in the treatment of offenders, there are still areas that require further refinement. There are several levels of care available, ranging from drug monitoring to resi-
Address correspondence to Dr C. Brendan Clark, PhD, University of Alabama at Birmingham, 401 Beacon PKWY W, Birmingham, AL 35209, USA; E-mail: [email protected]
836
TREATMENT COMPLETION
which likely reflects less severe drug use and criminal history among individuals sentenced to probation (Chandler et al., 2009) compared with individuals who get incarcerated. The severity of drug use has also been demonstrated to be a robust predictor of treatment failure (Butzin et al., 2002; Jaffe, Du, Huang, & Hser, 2012; Roll et al., 2005), with cocaine and heroin use, in particular, being associated with poor prognosis (Evans et al., 2009; Jaffe et al., 2012). A history of mental illness has been linked to early drop-out (Hiller, Knight, & Simpson, 1999; Lang & Belenko, 2000). Motivation to change is associated with treatment retention, but the relationship between motivation and treatment completion in the criminal justice system is confounded by the fact that many clients are legally mandated to enter and remain in treatment (Brocato & Wagner, 2008; Knight, Hiller, Broome, & Simpson, 2000). However, pressure from the legal system to enter treatment in order to avoid incarceration does not necessarily diminish motivation to attend or be successful in treatment (Prendergast, Greenwell, Farabee, Farabee, & Yih-Ing, 2009). In fact, although the criminal justice population is often reluctant to enter treatment despite the obvious need (Darbro, 2009), legally mandated treatment has been shown to increase retention rates (Perron & Bright, 2008) and can be just as successful as self-referred treatment (Snyder & Anderson, 2009). Based on these findings, we predict that, in our current sample of individuals engaged in substance abuse treatment under community correction supervision, completion would be predicted by four things: (i) a lower level of care, (ii) not using cocaine or heroin, (iii) higher economic stability (as indicated by education and employment), and (iv) a lack of mental illness. Using empirical data to identify who will complete treatment has important clinical applications, many of which are specific to individuals monitored under the criminal justice system. The substance abuse and rehabilitations programs these individuals are diverted to are often financially supported by the state, and any effort to identify those likely to succeed at a specific level of treatment (e.g., drug testing only; outpatient treatment, inpatient treatment, incarceration) has the potential to be financially beneficial to the system. Identifying appropriate candidates for a level of care may also reduce clinician burnout and improve treatment outcomes by appropriately matching need to level of care (Deutsch, 1984; Farber, & Heifetz, 1982). Furthermore, substance abuse treatment has been repeatedly demonstrated as an effective means of rehabilitating members of the criminal justice system, which aids not only this population, but benefits society as a whole through the associated reduction in recidivism and crime (Meyer, & Ritter, 2001; Sherman, Farrington, Welsh, & MacKenzie, 2002; Wild, Roberts, & Cooper, 2002). METHOD Sample
The participants in the current study comprised 615 individuals under community-corrections (i.e., probation, pa-
837
role, and individuals serving their sentence in the community) supervision in a midsized city in the southeastern United States. Individuals were referred to treatment directly from the courts, through the Department of Human Resources, or from another branch of legal supervision (e.g., Treatment Alternatives for Safer Communities). The data was collected via a chart-review of all individuals admitted to the treatment facility selected for this study from (August 2009 until June 2011). Treatment
The treatment followed a 12-step group format, and the average length of time of treatment was 91 days (SD = 214). Men and women attended separate groups. Upon entry into the program, participants completed a 1.5-hour assessment, which examined different areas of psychosocial functioning including substance abuse history, mental health needs, medical problems, vocational and educational needs, and social support. Participants were required to provide random UDS and paid for treatment services on a sliding scale. Although the overall focus of treatment was on recovery from drugs and alcohol, referrals were made for other problems including psychiatric services, General Equivalency Diploma (GED) classes, job skills, parenting classes, and medical treatment referrals. Thus, the treatment was tailored to the unique needs of the clients. To increase engagement and retention in treatment, transportation and onsite childcare was provided to clients. Predictor Variables
At treatment entry, all clients were assessed on a variety of psychosocial domains through face-to-face interviews with an assessment counselor. To determine mental health needs, the Mini-International Neuropsychiatric Interview (MINI) was administered. The mood and anxiety disorders were collapsed into general categories. Specifically, the variable “Depressive Disorders” was composed of participants who screened positive for either Major Depressive Disorder, Major Depressive Disorder with melancholic features, or Dysthymia. The variable “Anxiety Disorders” comprised participants who screened positive for one or more of the following: Generalized Anxiety Disorder, Social Phobia, Posttraumatic Stress Disorder, Panic Disorder, Agoraphobia, or Obsessive Compulsive Disorder. The item determining whether someone was currently having suicidal ideation was also extracted from the MINI. The drug category of “Opioid Use” was composed of people who used heroin or opioid medications such as methadone or other analgesics without a prescription. The criminal history categories were also composite variables composed of groups of related offenses. Person Offenses comprised individuals who had been charged with assault, robbery, harassment, rape, domestic violence, and child/elder abuse. Property Offenses was composed of auto theft, burglary, criminal trespassing, reception of stolen property, fraudulent use of a credit card, shoplifting, theft, and negotiating a worthless negotiable instrument (“bad checks”). Alcohol Offenses comprised
838
C. B. CLARK ET AL.
individuals who were arrested for driving under the influence, minor in possession, and public intoxication. Illicit Drug Offenses comprised individuals who were arrested for distribution and possession. Court Offenses comprised people who had a probation violation or failed to appear in court. The level of care that the participants were referred to post intake was also included in the analyses. Referral to level of care was based on the structured face-to-face clinical interview conducted by a master’s level therapist. The referral was based primarily on the individual’s severity of addiction, while taking into account: history of addiction, mental and physical health, and psychosocial functioning. The first level of care (n = 132, 21.5%) comprised individuals who attended Alcoholics Anonymous/Narcotics Anonymous meetings and attended one recovery group a week. The second level of care (n = 416, 67.6%) comprised individuals who attended three recovery groups a week. The final level of care (n = 61, 9.9%) was composed of individuals who were either referred to inpatient hospitalization before attending treatment or to intensive 5-days-a-week recovery classes. In addition, there were six (1%) individuals who were excluded from treatment due to missing data on this variable. Criterion Variables
The outcome variable was dichotomous for whether the participant successfully completed treatment. Successful completion depended on a number of factors such as compliance with treatment rules, sustained negative UDS, and regularly attending group. If participants were not compliant with treatment rules or presented multiple positive UDS, recommendations were made that they be transferred to a higher level of care which prolonged their stay in treatment. Analyses
The univariate associations between the predictor and criterion variables were first assessed through a series of binary logistic regressions. Variables that met a significance level of 0.05 were then included in a multivariate model. The multivariate model was created to examine the unique contribution of psychopathology, social stability, and substance use to treatment completion. RESULTS
Overall, 117 (19%) people successfully completed treatment, 471 (77%) people did not complete, and 27 (4%) people had missing data for the treatment outcome variable. The average stay in treatment was 91 (SD = 214) days, with successful completers (Mean = 160, SD = 98; Median = 133) remaining in treatment significantly longer than those who did not complete (Mean = 75, SD = 230; Median = 64; F = 13.5, P < 0.001). Univariate comparisons are presented in Table 1. Those who successfully completed treatment tended to be older, White, more educated, employed, entered treatment at a lower level of care, met criteria for an anxiety disorder, reported current suicidal ideation, had been charged with an
alcohol offense, reported alcohol use, and were less likely to have committed a property or court offense and report cocaine or opioid use. In addition, it should be noted that only 13.2% of the sample met criteria for an anxiety disorder despite relatively high reports of exposure to trauma (self-reported history of child abuse = 22%; self-reported history of exposure to a traumatic event = 36%). Results of the multivariate model (−2 Log Likelihood = 370.58; Cox & Snell R-Square = 0.21) are shown in Table 1. Successful outcome was associated with: older age, White race, having greater than a high school education, being referred to the lowest level of care, meeting criteria for an anxiety disorder, reporting suicidal ideation, and not having a history of opioid use. None of the criminal history variables were significantly associated with treatment outcome. Level of care was the most powerful indicator of outcome, because being referred to the lowest level of care produced the largest effect size in the model (OR = 19.64). Reporting current suicidal ideation (OR = 6.02) produced the second largest effect size, whereas the remaining significant associations demonstrated more modest effects. DISCUSSION
The results of this study were as expected with one notable exception. Both self-report of an anxiety disorder and report of suicidal ideation were associated with a positive outcome. The bulk of evidence seems to indicate that psychopathology is associated with treatment dropout, relapse, and is, generally, a signal of poor prognosis in the treatment of substance abuse (Gil-Rivas, Prause, & Grella, 2009). In the criminal justice population this literature is mixed and there is scant evidence to suggest that endorsing psychopathology may be linked to motivation and retention in treatment (Gray & Saum, 2005; Hiller et al., 2009). Estimates of mental health problems in the criminal justice system range drastically. However, the Bureau of Justice Statistics (2006b) estimates that approximately half the criminal justice population suffers from a mental illness. Given that this sample was under legal supervision combined with the high rates of unemployment (49%), self-reported history of child abuse (22%), and self-reported history of exposure to a traumatic event (36%), the fact that only 13% of the sample endorsed criteria for an anxiety disorder may represent underreporting. Essentially, a diagnosis of anxiety, depression, or suicidal ideation may be a better indication of who is willing to admit to these problems as opposed to who genuinely suffers from these problems. The reason for this underreporting may be linked to the culture of the criminal justice system. The culture of the criminal justice population has been described as overly masculine, image conscious, and predominantly focused on not showing weakness (Hendry, 2009; Kupers, 2005). In other words, it has been described as a “culture of honor,” or one which highly values the virtues of strength, courage, and self-reliance, and where asking for help is considered a sign of weakness. These cultures tend to be
839
TREATMENT COMPLETION
TABLE 1. Results of univariate and multivariate logistic regressions predicting treatment completion (n = 615) Univariate Characteristics Age (older) Gender (Female) Race (White) Education High school Employment Unemployed (ref) Disabled/retired Employed Living Situation In shelter (ref) With family Other Independent Treatment Type AA or brief IOP Inpatient or day treatment Anxiety Disorder Depressive Disorder Suicidal Ideation Person Offense Property Offense Alcohol Offense Illicit Drug Offense Court Offense Alcohol Use Marijuana Use Cocaine Use Opioid Use
Multivariate
Mean (SD) or %
OR
p
95% CI
OR
P
95% CI
34.5 (10.9) 35.1% 50.2%
1.03 0.97 2.30
.001 .899
ORIGINAL ARTICLE
Anxiety and Suicidal Ideation Predict Successful Completion of Substance Abuse Treatment in a Criminal Justice Sample C. Brendan Clark, Peter S. Hendricks, Ashley Brown and Karen L. Cropsey University of Alabama at Birmingham, Birmingham, USA dential treatment, and there are modalities available both for incarcerated individuals and those being supervised in the community. Tailoring treatment to the unique needs of members of the criminal justice system remains a critical necessity (NIDA, 2006), especially as the number of people in the criminal justice system continues to grow. Although the efficacy of treatment has been established, there has been very little research examining the client characteristics associated with success in the criminal justice system. The identification of characteristics linked to success at different levels of care, and the subsequent matching of client need to corresponding treatment, is an important step in not only reducing the cost of treatment for offenders but also of increasing the efficacy of the system, identifying the best timing for interventions, and reducing clinician burnout. Treatment completion has often been used a proxy of treatment success and efficacy (Butzin, Saum, & Scarpitti, 2002; Evans, Li, & Hser, 2009; MateyokeScrivner, Webster, Staton, & Leukefeld, 2004; Roll, Prendergast, Richardson, Burdon, & Ramirez, 2005), because completing treatment demonstrates stability and often requires maintaining negative urine drug screens (UDS) as well as staying out of legal trouble. The literature has identified a number of specific characteristics associated with treatment completion in the criminal justice population including steady employment and higher education (Brown, 2010, Butzin et al., 2002; Roll et al., 2005). However, members of the criminal justice system are typically faced with numerous barriers to treatment (i.e., lack of health insurance, unreliable transportation, unemployment, and unstable living situation), which may explain why economic stability appears to be a more salient predictor of outcome in this specific population than in more affluent ones (Sung, Mahoney, & Mellow, 2010; Taxman, 1998). Similarly, individuals on probation (sentenced to serve time under supervision in the community rather than incarceration) tend to do better than those on parole (sentenced to community supervision after incarceration),
The goal of this study was to identify predictors of successful substance abuse treatment in an out-patient clinic for individuals being monitored under community corrections supervision. Of the 615 participants, 117 (19%) successfully completed treatment. The results of a multivariate logistic regression analysis indicated that successful treatment was associated with several baseline characteristics including: older age, White race, having greater than a high school education, lower level of care, meeting criteria for an anxiety disorder, reporting suicidal ideation, and not having a history of opioid use. The value of self-report of problems and its influence on treatment in the culture of the criminal justice population is discussed in this article. Keywords criminal justice, community corrections, treatment completion, anxiety, suicidal ideation
INTRODUCTION
Approximately 50% of individuals in the criminal justice system meet criteria for a substance use disorder (SUD; ref. Bureau of Justice Statistics, BJS, 2006a; Kubiak, Arfken, Swartz, & Koch, 2006). Although the persistence of SUDs is associated with increased rates of recidivism (Walter et al., 2011), treating these disorders reduces repeated criminal behavior, benefiting both the criminal justice population and society as a whole (Peters & Murrin, 2000). Although punitive sanctions are ineffective at reducing drug use, SUD treatment has repeatedly been shown to benefit substance users in the criminal justice system (Chandler, Fletcher, & Volkow 2009; Fielding, Tye, Ogawa, Imam, & Long, 2002), with the cost of treatment approximately five times less expensive than incarceration (National Institute of Drug Abuse, 2006; TASC.org, 2011). Despite the tremendous progress made in the treatment of offenders, there are still areas that require further refinement. There are several levels of care available, ranging from drug monitoring to resi-
Address correspondence to Dr C. Brendan Clark, PhD, University of Alabama at Birmingham, 401 Beacon PKWY W, Birmingham, AL 35209, USA; E-mail: [email protected]
836
TREATMENT COMPLETION
which likely reflects less severe drug use and criminal history among individuals sentenced to probation (Chandler et al., 2009) compared with individuals who get incarcerated. The severity of drug use has also been demonstrated to be a robust predictor of treatment failure (Butzin et al., 2002; Jaffe, Du, Huang, & Hser, 2012; Roll et al., 2005), with cocaine and heroin use, in particular, being associated with poor prognosis (Evans et al., 2009; Jaffe et al., 2012). A history of mental illness has been linked to early drop-out (Hiller, Knight, & Simpson, 1999; Lang & Belenko, 2000). Motivation to change is associated with treatment retention, but the relationship between motivation and treatment completion in the criminal justice system is confounded by the fact that many clients are legally mandated to enter and remain in treatment (Brocato & Wagner, 2008; Knight, Hiller, Broome, & Simpson, 2000). However, pressure from the legal system to enter treatment in order to avoid incarceration does not necessarily diminish motivation to attend or be successful in treatment (Prendergast, Greenwell, Farabee, Farabee, & Yih-Ing, 2009). In fact, although the criminal justice population is often reluctant to enter treatment despite the obvious need (Darbro, 2009), legally mandated treatment has been shown to increase retention rates (Perron & Bright, 2008) and can be just as successful as self-referred treatment (Snyder & Anderson, 2009). Based on these findings, we predict that, in our current sample of individuals engaged in substance abuse treatment under community correction supervision, completion would be predicted by four things: (i) a lower level of care, (ii) not using cocaine or heroin, (iii) higher economic stability (as indicated by education and employment), and (iv) a lack of mental illness. Using empirical data to identify who will complete treatment has important clinical applications, many of which are specific to individuals monitored under the criminal justice system. The substance abuse and rehabilitations programs these individuals are diverted to are often financially supported by the state, and any effort to identify those likely to succeed at a specific level of treatment (e.g., drug testing only; outpatient treatment, inpatient treatment, incarceration) has the potential to be financially beneficial to the system. Identifying appropriate candidates for a level of care may also reduce clinician burnout and improve treatment outcomes by appropriately matching need to level of care (Deutsch, 1984; Farber, & Heifetz, 1982). Furthermore, substance abuse treatment has been repeatedly demonstrated as an effective means of rehabilitating members of the criminal justice system, which aids not only this population, but benefits society as a whole through the associated reduction in recidivism and crime (Meyer, & Ritter, 2001; Sherman, Farrington, Welsh, & MacKenzie, 2002; Wild, Roberts, & Cooper, 2002). METHOD Sample
The participants in the current study comprised 615 individuals under community-corrections (i.e., probation, pa-
837
role, and individuals serving their sentence in the community) supervision in a midsized city in the southeastern United States. Individuals were referred to treatment directly from the courts, through the Department of Human Resources, or from another branch of legal supervision (e.g., Treatment Alternatives for Safer Communities). The data was collected via a chart-review of all individuals admitted to the treatment facility selected for this study from (August 2009 until June 2011). Treatment
The treatment followed a 12-step group format, and the average length of time of treatment was 91 days (SD = 214). Men and women attended separate groups. Upon entry into the program, participants completed a 1.5-hour assessment, which examined different areas of psychosocial functioning including substance abuse history, mental health needs, medical problems, vocational and educational needs, and social support. Participants were required to provide random UDS and paid for treatment services on a sliding scale. Although the overall focus of treatment was on recovery from drugs and alcohol, referrals were made for other problems including psychiatric services, General Equivalency Diploma (GED) classes, job skills, parenting classes, and medical treatment referrals. Thus, the treatment was tailored to the unique needs of the clients. To increase engagement and retention in treatment, transportation and onsite childcare was provided to clients. Predictor Variables
At treatment entry, all clients were assessed on a variety of psychosocial domains through face-to-face interviews with an assessment counselor. To determine mental health needs, the Mini-International Neuropsychiatric Interview (MINI) was administered. The mood and anxiety disorders were collapsed into general categories. Specifically, the variable “Depressive Disorders” was composed of participants who screened positive for either Major Depressive Disorder, Major Depressive Disorder with melancholic features, or Dysthymia. The variable “Anxiety Disorders” comprised participants who screened positive for one or more of the following: Generalized Anxiety Disorder, Social Phobia, Posttraumatic Stress Disorder, Panic Disorder, Agoraphobia, or Obsessive Compulsive Disorder. The item determining whether someone was currently having suicidal ideation was also extracted from the MINI. The drug category of “Opioid Use” was composed of people who used heroin or opioid medications such as methadone or other analgesics without a prescription. The criminal history categories were also composite variables composed of groups of related offenses. Person Offenses comprised individuals who had been charged with assault, robbery, harassment, rape, domestic violence, and child/elder abuse. Property Offenses was composed of auto theft, burglary, criminal trespassing, reception of stolen property, fraudulent use of a credit card, shoplifting, theft, and negotiating a worthless negotiable instrument (“bad checks”). Alcohol Offenses comprised
838
C. B. CLARK ET AL.
individuals who were arrested for driving under the influence, minor in possession, and public intoxication. Illicit Drug Offenses comprised individuals who were arrested for distribution and possession. Court Offenses comprised people who had a probation violation or failed to appear in court. The level of care that the participants were referred to post intake was also included in the analyses. Referral to level of care was based on the structured face-to-face clinical interview conducted by a master’s level therapist. The referral was based primarily on the individual’s severity of addiction, while taking into account: history of addiction, mental and physical health, and psychosocial functioning. The first level of care (n = 132, 21.5%) comprised individuals who attended Alcoholics Anonymous/Narcotics Anonymous meetings and attended one recovery group a week. The second level of care (n = 416, 67.6%) comprised individuals who attended three recovery groups a week. The final level of care (n = 61, 9.9%) was composed of individuals who were either referred to inpatient hospitalization before attending treatment or to intensive 5-days-a-week recovery classes. In addition, there were six (1%) individuals who were excluded from treatment due to missing data on this variable. Criterion Variables
The outcome variable was dichotomous for whether the participant successfully completed treatment. Successful completion depended on a number of factors such as compliance with treatment rules, sustained negative UDS, and regularly attending group. If participants were not compliant with treatment rules or presented multiple positive UDS, recommendations were made that they be transferred to a higher level of care which prolonged their stay in treatment. Analyses
The univariate associations between the predictor and criterion variables were first assessed through a series of binary logistic regressions. Variables that met a significance level of 0.05 were then included in a multivariate model. The multivariate model was created to examine the unique contribution of psychopathology, social stability, and substance use to treatment completion. RESULTS
Overall, 117 (19%) people successfully completed treatment, 471 (77%) people did not complete, and 27 (4%) people had missing data for the treatment outcome variable. The average stay in treatment was 91 (SD = 214) days, with successful completers (Mean = 160, SD = 98; Median = 133) remaining in treatment significantly longer than those who did not complete (Mean = 75, SD = 230; Median = 64; F = 13.5, P < 0.001). Univariate comparisons are presented in Table 1. Those who successfully completed treatment tended to be older, White, more educated, employed, entered treatment at a lower level of care, met criteria for an anxiety disorder, reported current suicidal ideation, had been charged with an
alcohol offense, reported alcohol use, and were less likely to have committed a property or court offense and report cocaine or opioid use. In addition, it should be noted that only 13.2% of the sample met criteria for an anxiety disorder despite relatively high reports of exposure to trauma (self-reported history of child abuse = 22%; self-reported history of exposure to a traumatic event = 36%). Results of the multivariate model (−2 Log Likelihood = 370.58; Cox & Snell R-Square = 0.21) are shown in Table 1. Successful outcome was associated with: older age, White race, having greater than a high school education, being referred to the lowest level of care, meeting criteria for an anxiety disorder, reporting suicidal ideation, and not having a history of opioid use. None of the criminal history variables were significantly associated with treatment outcome. Level of care was the most powerful indicator of outcome, because being referred to the lowest level of care produced the largest effect size in the model (OR = 19.64). Reporting current suicidal ideation (OR = 6.02) produced the second largest effect size, whereas the remaining significant associations demonstrated more modest effects. DISCUSSION
The results of this study were as expected with one notable exception. Both self-report of an anxiety disorder and report of suicidal ideation were associated with a positive outcome. The bulk of evidence seems to indicate that psychopathology is associated with treatment dropout, relapse, and is, generally, a signal of poor prognosis in the treatment of substance abuse (Gil-Rivas, Prause, & Grella, 2009). In the criminal justice population this literature is mixed and there is scant evidence to suggest that endorsing psychopathology may be linked to motivation and retention in treatment (Gray & Saum, 2005; Hiller et al., 2009). Estimates of mental health problems in the criminal justice system range drastically. However, the Bureau of Justice Statistics (2006b) estimates that approximately half the criminal justice population suffers from a mental illness. Given that this sample was under legal supervision combined with the high rates of unemployment (49%), self-reported history of child abuse (22%), and self-reported history of exposure to a traumatic event (36%), the fact that only 13% of the sample endorsed criteria for an anxiety disorder may represent underreporting. Essentially, a diagnosis of anxiety, depression, or suicidal ideation may be a better indication of who is willing to admit to these problems as opposed to who genuinely suffers from these problems. The reason for this underreporting may be linked to the culture of the criminal justice system. The culture of the criminal justice population has been described as overly masculine, image conscious, and predominantly focused on not showing weakness (Hendry, 2009; Kupers, 2005). In other words, it has been described as a “culture of honor,” or one which highly values the virtues of strength, courage, and self-reliance, and where asking for help is considered a sign of weakness. These cultures tend to be
839
TREATMENT COMPLETION
TABLE 1. Results of univariate and multivariate logistic regressions predicting treatment completion (n = 615) Univariate Characteristics Age (older) Gender (Female) Race (White) Education High school Employment Unemployed (ref) Disabled/retired Employed Living Situation In shelter (ref) With family Other Independent Treatment Type AA or brief IOP Inpatient or day treatment Anxiety Disorder Depressive Disorder Suicidal Ideation Person Offense Property Offense Alcohol Offense Illicit Drug Offense Court Offense Alcohol Use Marijuana Use Cocaine Use Opioid Use
Multivariate
Mean (SD) or %
OR
p
95% CI
OR
P
95% CI
34.5 (10.9) 35.1% 50.2%
1.03 0.97 2.30
.001 .899
