“Treatment Outcome Models” by Matthew D. Geyer (2009).

FPSY 6511 Treatment of Forensic Populations

Treatment Outcome Models By Matthew D. Geyer 2009

The Case of Sandy:

Sandy Lee is a 28-year-old woman who was arrested and convicted of trafficking in

cocaine. As a component of her incarceration, the court required her to participate in a

residential treatment program followed by outpatient substance abuse counseling when

she was released from prison. During her time in the residential treatment program, she

participated regularly in the group meetings and even sought individual counseling for

problems associated with past abusive relationships. Shortly after Sandy completed the

program, she was paroled and lived in a halfway house for approximately six months.

She saw a substance abuse counselor on a weekly basis in addition to attending weekly

group support sessions. Sandy also saw a psychiatrist every three months to maintain

her on an antidepressant that was prescribed by the prison psychiatrist after Sandy was

diagnosed with generalized anxiety disorder. Upon discharge from the halfway house,

she moved into an apartment, was reunited with her children, and was able to maintain

stable employment.

Four months after she had been in her own apartment with her children and maintaining

a job, she was selected by her parole officer to participate in random drug testing. Three

days prior to being tested, she went out on a date to a local bar. She and her date went

outside and he offered her some marijuana. Although Sandy knew the risks, she also

was not concerned because she had not been tested in more than three months and

was certain that one “smoke” would not create problems for her. At the time, she told

herself, “This is just going to let me enjoy tonight a bit more…I haven’t smoked

marijuana in four years and I am not planning on dealing again.”

As a result of a positive drug screen three days later, her parole officer had her

arrested. She was returned to jail on a “technical violation” of her parole. She went

before the judge two weeks later and he revoked her parole. The judge removed her

children from her custody and returned them to the care of a trusted family member.

She was returned to prison and was advised by the judge to seek further treatment.

“Treatment Outcome Models” by Matthew D. Geyer (2009).

Some Questions to Ponder:

This is a real case that occurred in the not-too-distant past. Before beginning a

discussion of treatment outcomes and treatment outcome models, there are some

questions to consider:

1. Was Sandy’s original prison stay for substance abuse treatment a success?

2. Did Sandy’s outpatient treatment program result in a successful outcome?

3. Why did the judge return Sandy to prison after she tested positive for the use of

marijuana? What does this say about this court’s view of treatment and treatment

outcomes?

4. If you were a researcher for any of the programs mentioned in this scenario, what

outcomes would you focus on and measure, and how would you measure the

outcomes? What would constitute success? What would constitute failure? Could

there be different definitions of success and failure for different treatment

models?

The Nature of Treatment Outcomes:

Treatment outcomes are important to the research question(s) being asked. Any

research effort must identify how treatment success is achieved. Interestingly, this

leaves the possibility that several types of outcomes are addressed in the literature

using the same approach. Each person or role in a forensic setting may have a specific

way in which success is determined. For instance, the court may consider success as

the individual not returning, for any reason, to the justice system. The warden at the

prison may consider a treatment program successful if it reduces the number of

institutional offenses of the participating inmates. And the therapists in the treatment

program might view success as the participant’s increased frequency of contact with

family members. Simply stated, each interested party in the process has his or her own

view of how treatment success is defined. In addition to the “players” mentioned above

(e.g., those in the courts, prisons, treatment venues, and other forensic settings), the

other interested party in what determines treatment success is the person receiving the

treatment services. The client might view treatment success differently from some or all

of the players in forensic settings. For instance, the person who is required to participate

in treatment as a condition of release from prison might view the only real desirable

outcome as release from prison. Yet other individuals might have ulterior motives for

treatment, such as gaining the attention of family members.

“Treatment Outcome Models” by Matthew D. Geyer (2009).

Concisely, treatment outcome is dependent on the viewpoint of the person or group

being asked, “What is a desirable outcome of this treatment?” At times, there may be

convergence among people in forensic settings and/or researchers on what this means,

but at other times, competing research paradigms (treatment outcomes) have different

definitions of success. Therefore, when the professional literature is reviewed, it is

important to consider the view represented in the definition of the outcome and its

success or failure. A successful outcome for one group may be different from a

successful outcome of another group.

Returning to the case of Sandy Lee, treatment outcomes might be viewed as noted by

the various interested parties:

1. Sandy Lee: Treatment may be viewed as a failure because she went back to

prison.

2. Court: Treatment may be viewed as a success because no new charge was

made for drug selling.

3. Treatment program: Treatment may be viewed as a failure due to the positive

drug screen.

4. Sandy’s mother: Treatment may be viewed a success because as soon as a

problem was identified, she was brought back into a more structured setting for

help.

5. Sandy’s parole officer: Treatment may be viewed as a failure because Sandy

was returned to prison.

6. Sandy’s boyfriend: Treatment may be viewed as a success because their

relationship improved.

The point here is that the facts of the case have not changed, only the view of what

constitutes treatment success. This information is relevant not only for the researcher

but also for the clinician in the forensic treatment setting. Being able to recognize the

desired outcome by the particular stakeholders gives the clinician an ability to

understand how competing views might define success and failure when it comes to

treatment outcomes.

Three Dominant Models

In the forensic treatment professional literature, there are three dominant models of

outcomes that are discussed: recidivism, relapse, and harm-reduction. These three

models have a direct impact on the definition of a desired treatment outcome, how

research is planned, and goals for treatment. Understanding these models not only will

“Treatment Outcome Models” by Matthew D. Geyer (2009).

help clinicians understand the clinical and practice literature but also will help them plan

for treatment in forensic settings.

Recidivism Model

Simply stated, and as defined in professional literature, recidivism is a person returning

to prison. Although the overall notion of recidivism is the return to previous behavior

patterns, the reality of the concept remains focused on the offender doing something,

being caught, and then being returned to the criminal justice system. A review of

numerous recidivism studies use “the return of a person to prison” as the measure of

recidivism. Recidivism studies do not look at specific issues that led the person back,

but look only at the situation as a binary outcome: returned or not returned.

In the case of Sandy Lee, she would be considered a treatment failure in the prison

treatment program if viewed from the typical recidivism model. When incarcerated, she

went through the treatment program and completed the overall program. Because she

returned to the prison setting (the actual reason is not a consideration), Sandy would be

considered a treatment failure according to the recidivism model.

One of the biggest drawbacks of the recidivism model is that it does not take into

account why the person is returned to prison. In Sandy’s case, she was returned to

prison because of a technical violation of her parole (testing positive for drug use). The

reason for the return is given the same weight as any reason, whether related to original

reason for incarceration of not. For example, testing positive for drug abuse carries the

same weight as would a murder charge.

One of the benefits of using this outcome model is that it is easy to “measure” with

typical law enforcement records. Using criminal offense databases, prison records, and

court documents, treatment outcomes related to recidivism may be measured without

actually needing to conduct assessments of the actual individuals involved. Recidivism

is easy to count and the inner rater reliability easily is established.

Relapse Model

Relapse means a return to a previous set of behaviors or mental state. The term

“relapse” actually comes from the literature related to addictions and constitutes a major

portion of the relapse prevention literature (e.g., Gordon and Marlatt’s model) and

literature related to the traditional medical model (e.g., the Alcoholics Anonymous

disease model). The term “relapse” often is associated with medical and psychological

models and supports the disease model. Relapse is considered part of a larger process

that is unique to the individual. More importantly, the disease model and the traditional

relapse prevention model relate to relapse as a normal event that needs to be

addressed through treatment. It is not considered as “bad” and is seen as a part of the

overall process of “recovery.”

“Treatment Outcome Models” by Matthew D. Geyer (2009).

In the case of Sandy Lee, reflecting this relapse perspective, a relapse occurred when

she smoked marijuana on her date. The relapse model also would suggest that there

were events that led to the relapse. For instance, she may have been aware that her

date had a history of using marijuana but still made the decision to go out with him. She

placed herself in a relapse situation by going on the date in the first place. The fact that

she was selected for the drug test and returned to prison is not relevant in the relapse

perspective literature. The relapse model focuses solely on the return to previous

behavior patterns or ways of behaving.

The relapse model is consistent with many of the medical and psychological models of

behavior. It views behavior as cyclical and complex. The relapse prevention model has

been well researched and has a strong base of data to support it. A benefit of the

relapse model is that it is consistent with treatment efforts and it does not view the

person as a treatment failure for just one reoccurrence of behavior, which is often

referred to as a lapse. Lapses often are used in treatment as learning experiences

where the client works to understand the pattern and how to prevent having a full

relapse.

The difficulty of the model, however, is that it is difficult to measure accurately. In the

criminal justice system and various forensic settings, there are considerable costs

associated with reporting a lapse or relapse. The client who has experienced a

lapse/relapse is likely to hide the occurrence out of fear of sanctions. Many forensic

treatment providers are required to report relapses; therefore, the client, again, may

choose to hide problems. This situation makes accurate measurement of the

occurrence of any targeted behavior difficult due to the possibility of withheld

information because of sanctions that would be imposed if the relapse was to be

revealed.

Harm-Reduction Model

The third treatment outcome model described in forensic literature is the harm-reduction

model. Of the three models, this model probably has been researched the least and is

mentioned infrequently. Interestingly, it is the model that many clinicians support (in

theory). According to the harm-reduction model, treatment is successful if less harm is

done as a result of going through treatment as compared to no treatment at all. For

example, a pedophile who goes through a treatment program for pedophilia could be

considered a treatment success even if he is returned to prison for a lesser charge.

Specifically, if this sex offender is returned to prison for possession of child pornography

and not re-offending against an actual child, he would be considered a treatment

success (less harm was done to an identifiable victim). Another example is a person

who completes a program for violent behavior but returns to the treatment setting for

“Treatment Outcome Models” by Matthew D. Geyer (2009).

damaging personal property without doing direct physical harm to a person. His or her

aggressive behavior was reduced in terms of harmful impact to identifiable others.

When considering Sandy Lee’s case, the harm-reduction model might consider her

initial treatment a success because she did not return to prison for trafficking a

controlled substance but only for a parole violation (not a new charge). The harm-

reduction model would view success as fewer people being damaged by her return to

maladaptive behaviors.

One of the primary benefits of using a harm-reduction model for treatment outcome

measurement is that it may offer a better option than the “all or none” approach of the

other models, and therefore may be more realistic when dealing with human behavior. It

not only considers the frequency of the behavior but also takes into account the quality

of the behavior. This model is reflected in some of the needle-sharing programs for

heroin addicts in Europe as well as in HIV prevention programs that distribute condoms

in Africa. Both of these programs are built on the harm-reduction model.

As with any outcome target, concerns are raised in the research. Some of the most

popular criticisms of the harm-reduction model involve difficulty in measurement. For

instance, a sex offender who does not physically harm an identifiable person by

watching child pornography still is engaging in a maladaptive and deviant behavior. To

say it causes less harm could be viewed as inaccurate (the children exploited in the

material are victims as well). Moreover, the drug addict who uses less frequently is still

at increased risk for other difficulties. Thus it is the qualitative aspect of the harm-

reduction model that creates difficulty with quantitative measurement.

The Best Model

Given that these three models are evident throughout the professional literature, some

have asked which is the best of the three. In fact, this is a question researchers must

address when they set out to conduct a study or create an outcome measure for a given

treatment plan. Moreover, since many programs are funded based on their outcomes,

the choice of a model may have significant implications.

Each of these models has utility, and each offers a different perspective on a problem

and its outcome. According to the author of this manuscript, a good researcher,

clinician, and student considers each model in a specific situation to get an idea of the

“big picture” and possible approaches to treatment and measurement of success. Said

another way, each of the models allows the clinical researcher to get a view of a

particular problem from a slightly different perspective, which may help in the

development of an overall treatment outcome plan.

A particular benefit of understanding and being familiar with the research related to

each of these models is that it supports the clinician in effectively speaking about how

“Treatment Outcome Models” by Matthew D. Geyer (2009).

treatment works and helps him or her to set realistic outcomes for the client, the

program, the courts, and so on. In the end, the best model is one that is used

appropriately for the targeted problem or issue. This must occur in a climate that

encourages an understanding, by interested parties, of the complexities of the treatment

approach being utilized, and understanding how each model might or might not

adequately capture the entire picture presented by the behavior in question.

Some Tips for Reading the Literature

The articles reviewed for any course in forensic treatment methods should be based on

good science and research methods. As a scholar/practitioner, you should keep several

key points in mind while perusing the literature. As a tool, the following questions to ask

yourself are offered to assist you in gaining an appreciation for treatment outcomes.

1. What treatment outcome model is being used — Relapse, Recidivism, Harm-

Reduction, or a combination of all three?

2. Is the author presenting a limited view of the specific behavior by relying on only

one model or on a model that is limited given the study? If so, what might this do

to the results presented as well as the conclusions drawn?

3. Are there any risks to the author (or organization) if one type of treatment

outcome model is considered? Would these risks create bias or inaccurate

conclusions?

4. If the study reviewed was to be replicated using a different model, how might the

results be similar and/or different?

These are four basic questions that can assist you in reading the outcome literature to

provide a deeper understanding of the article as it relates to treatment outcomes.

One Final Caveat

The three treatment outcome models discussed not only have implications for the

clinician and the forensic settings in which they work but also have very real meanings

to the people who are undergoing the treatment. Sandy Lee presents a complicated

case in that she was returned to prison for a parole violation, lost time with her children,

lost the support of her boyfriend, and lost her freedom. Regardless of the model used to

measure success of the treatment program, these are very real experiences for the

person receiving treatment in the forensic treatment venue.

Treatment outcomes often are reported as facts in the literature. They are presented as

numbers and results that remove any personal identifying information. A clinician in the

forensic treatment setting, losing sight of the human cost to the client and the affected

families, can become less potent as a care provider. While this does not mean a

clinician acts to prevent natural and appropriate consequences for behavior, it does call

on forensic treatment professionals to remain invested in understanding the individual

“Treatment Outcome Models” by Matthew D. Geyer (2009).

experience of their clients and how treatment outcomes might impact their lives and the

lives of those around them.

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