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Relapse Prevention Approaches with Drug-abusing Offenders

—Roger H. Peters, Ph.D., Department of Law and Mental Health, Florida Mental Health Institute, University of South Florida

In recent years, an overwhelming number of offenders entering the criminal justice system are involved with alcohol or other drugs, including more than 70 percent of arrestees in several metropolitan areas. New arrestees testing positive for addictive drugs are charged with a wide range of crimes, including drug possession and sales, burglary/robbery, larceny/theft, prostitution, assault, and violation of probation or parole.

These crimes are often linked to drug use, either through illegal activities designed to obtain money for drugs, through violence associated with street sale of drugs, or through the effects of drugs or alcohol (by disinhibition) on violent behavior. In the recent Epidemiological Catchment Area (ECA) study conducted by the National Institute of Mental Health, a diagnosis of substance abuse was found to be the most powerful predictor of recent violence.

Risk factors for relapse

Most drug-involved offenders have repeatedly cycled through the criminal justice system. Their names and faces are all too familiar to police, probation officers, jail booking staff, judges, public defenders, and prosecutors. These individuals are extremely likely to be rearrested following release from incarceration, both because untreated offenders have a high rate of relapse to substance abuse, and because relapse tends to accelerate the level of criminal activity among this population. Key factors that contribute to the risk for relapse among drug-involved offenders include:

• A chronic history of substance abuse

• A poor history of involvement in substance abuse treatment

• Low socioeconomic status and/or unemployment

• Mental health symptoms

• Various stressors related to criminal justice supervision

• Inadequate skills for handling social pressures to use drugs

• Returning to inner city drug areas or families that provide exposure to the high risk situations (e.g. active drug users) associated with their previous use of drugs and alcohol

As prisons, juvenile detention centers, jails, and other community correctional facilities have become filled to capacity, programs are examining new solutions to prevent relapse, to reduce the demand for street drugs, and to diminish recidivism among drug-involved offenders. Increasingly, relapse prevention approaches are being adapted for use within criminal justice settings. These approaches include a variety of innovative strategies that can help offenders maintain their substance abuse treatment gains during the critical period when they reenter the community.

Relapse prevention strategies have been shown to be a useful adjunct to treatment at all stages: at the time of pretrial or presentence release, detention in jail or prisons, and during parole or probation. These strategies are particularly effective when used in support of such transition services as TASC programs (Treatment Alternatives to Street Crime). They assist offenders to prepare for the inevitable challenges faced during the critical first several months after they are released from a secure environment—the time when most relapses occur.

Principles of relapse prevention

Relapse prevention principles include learning to identify "high risk situations" and other antecedents to relapse, as well as the development of relapse coping skills. These principles provide a common vocabulary by which judicial, correctional, community treatment, and community supervision staff are able to conceptualize treatment goals for the drug-involved offender, to identify early warning signs of relapse, and to monitor progress following release from incarceration.

The psychoeducational approaches used in relapse prevention programs can be easily integrated within traditional modalities, including therapeutic communities, intensive outpatient treatment, and chemical dependency or 12-step programs. Relapse prevention programs include didactic and skills training components that encourage a highly structured treatment format. This structured approach has been shown to be effective with offenders. Relapse prevention focuses on the individual's responsibility for monitoring and preventing relapse episodes. Such personal responsibility is also consistent with the principles involving accountability for behavior that are endorsed by criminal justice administrators and staff.

Two current reports review the role of relapse prevention strategies within the larger framework of substance abuse treatment. One is Intervening with Substance-Abusing Offenders: A Framework for Action, issued by the National Institute of Corrections in 1991. A second report summarizing innovative relapse prevention approaches developed within the criminal justice system will soon be published by the Center for Substance Abuse Treatment and is titled, Relapse Prevention and the Substance-Abusing Criminal Offender. Relapse prevention approaches have worked effectively in pretrial and jail diversion programs, as well as in jails and in Federal and State prisons. (For examples of programs and their strategies, see the box.)

A number of specific relapse prevention techniques have been developed within criminal justice settings. These include:

1. Self-assessment. Offenders learn to assess their past relapse episodes, the factors contributing to recent substance abuse, and the coping skills they have used to manage and avoid past relapses.

2. Individual "behavior chains." Offenders are assisted to develop individualized "behavior chains" that describe the sequence of events preceding relapse, and to recognize that relapse is often prompted by several predictable events and changes in their behavior.

3. Self-monitoring and development of coping skills. Self-monitoring strategies are provided so that offenders can identify high risk situations and behaviors well in advance of a relapse episode. Offenders are then instructed to develop coping skills to manage high-risk situations, negative thoughts, excessive emotions and rationalizations, cues, and urges that often trigger a return to substance abuse.

4. Motivational strategies. Motivational interviewing strategies are often used in combination with relapse assessment. These help to enhance an offender's awareness of the consequences of substance abuse and to develop individual commitment to changing problem behaviors.

5. Other interventions. Other interventions deserve further examination for use with offenders. These include strategies to help identify criminal thinking errors and behaviors that may erode the person's commitment to recovery goals and that may contribute to relapse.

A graduated or "stepped-care approach should be used to match relapse prevention strategies to an offender's treatment needs. The choice of strategies should be consistent with the level of the offender's available coping skills and with how well the offender has used these skills in managing past relapses. Specialized, more intensive approaches may be appropriate for offenders who have experienced:

• Multiple cues, high risk situations, or other risk factors for relapse
• Few periods of successful abstinence
• Profound consequences associated with relapse that are likely to affect the larger community (e.g., high risk HIV/AIDS behavior, crime linked to drug use, domestic violence, and child abuse or neglect)

Intensive relapse prevention approaches may also be appropriate for many polydrug abusers and female addicts who are treated in criminal justice settings. For these populations, strategies should include consistent modeling and rehearsal of relapse skills, and monitoring the use of these skills during aftercare.

Planning for release to the community

Individualized relapse prevention plans are useful in developing treatment goals. Such a plan can address important relapse antecedents and can help monitor the offender's progress in implementing relapse coping skills. Dissemination of an offender's relapse prevention plan to community supervision and substance abuse treatment staff following release from a secure setting may help to identify high risk situations and other potential barriers to the recovery process, and may provide a measure of progress towards treatment goals.

Incarcerated offenders should be assisted in preparing a detailed plan of activities for the first few days following their release from jail or prison. This critical period is often marked by reunification with family or friends, desires to celebrate, and exposure to familiar relapse cues. A structured plan for transitional services needs to be developed well in advance of release that includes ongoing substance abuse treatment.

Program-level strategies

Several program-level strategies have been implemented to help prevent relapse among offenders. These include development of:

• Ex-offender peer support groups in the community

• Aftercare groups designed for ex-offenders

• Group interventions involving drug-free family members, designed to encourage development of a relapse prevention network and to alert family members to common relapse warning signs

• Handbooks for ex-offenders describing social services and other programs available in the community

The Center on Addiction and Substance Abuse (CASA) at Columbia University is the sponsor of an innovative services integration approach that will be extensively evaluated for its effectiveness. This demonstration, involving offenders released to the community after receiving treatment in criminal justice settings, will involve pilot programs in six to eight cities.

Programs will provide a coordinated system of case management, vocational training, housing assistance, family interventions, urinalysis monitoring, and graduated sanctions for rules violations. This initiative will feature extensive collaboration between community case managers and parole/probation officers, with a focus on use of common relapse prevention approaches.

Preventing relapse to substance abuse is critical if ex-offenders are to develop a productive healthy lifestyle and avoid returning to criminal activity related to drug addiction. We now have available an array of individual and program-level strategies to help these offenders develop the skills they need to prevent relapse. These relapse prevention techniques will be further refined as they are applied in a variety of criminal justice settings.

Research efforts have just begun to examine the effectiveness of innovative relapse prevention programs. Although preliminary results have been quite promising, additional outcome studies are needed to measure the long-term impact on abstinence from addictive substances and criminal recidivism.

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