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Arsenal of science
In the war on drugs, TCU's Institute of Behavorial Research provides innovative weapons
By Saedra Pinkerton
As the “war on drugs” battles through a third decade, jails are overcrowded and drugs more available than ever. In the federal system alone, drug offenders comprise more than half the inmate population.
Imprisoning drug users costs billions of tax dollars each year. Worse, those released from a traditional prison setting generally have limited skills for combating the problems that led them to abuse drugs in the first place. And extended exposure to other prisoners may have prepared them for a life of crime.
Policymakers, health-care and criminal justice providers in many states now urge treatment instead of locking up drug users. Increasingly, these people are turning to TCU’s Institute of Behavioral Research (IBR) for answers.
Headed by Dwayne Simpson ‘70 (PhD), IBR is one of several institutions spearheading the nation’s drug treatment research. The institute has received $35 million in grants over the last 15 years — roughly half of all federal grants garnered by the university. Most of the money has come from the National Institute on Drug Abuse (NIDA), and it apparently has been well-spent. Evidence gathered from IBR’s research has helped guide public funding for community-based treatment programs nationwide.
IBR researchers publish heavily, with more than 200 papers in professional journals and books. And their hands-on tools for professionals can be found on the institute’s award-winning Web site.
“We’ve made all of our research more user-friendly, giving flexibility to the practitioner,” Simpson said. “A counselor can pull something off the web, quickly review it, and begin working through it with a client. We offer prepackaged planning materials for communication skills, HIV health education and relapse prevention. And our material is unique, such as node-link mapping.”
FOUNDED IN 1962 by Saul B. Sells, IBR originally stressed personality theories. Pioneering IBR software evaluated prospective pilots to determine how they would function under pressure. In 1968, IBR forged into the relatively new field of substance abuse treatment, conducting the first national evaluation of community-based treatment for heroin.
As a graduate student, Simpson interviewed drug users in the large, prison-like facilities before the transition to community mental health centers. He eventually took over IBR, moving it to Texas A&M University for seven years. In 1989, TCU wooed Simpson back, and he shifted IBR to examining the treatment process.
“We asked, ‘How does treatment work?’ We developed a treatment process model, measuring motivation, engagement, early recovery, retention. It all fits together. A person’s chances increase significantly the longer he stays in treatment. We looked at how to keep people around. We developed interventions, targeted social skills, anything to pull the pieces together.”
In the early 1990s, sharing groundbreaking research was a lengthy endeavor. Then the Internet emerged and greatly speeded publishing and training.
“The Internet has been a key tool to make things happen the way we envisioned. Otherwise they can’t get stuff like this. It’s crucial,” Simpson said. “People on the Internet will write and thank us. They’ll tell us they’ve been using our materials for years.”
The success recently earned Simpson’s group the prestigious NIDA Merit Award. The award goes to only 1 percent of NIDA’s funded researchers and in this case, it provided for an additional five years of funding for IBR’s DATAR project.
MOST PEOPLE know someone touched by drug abuse — a parent, sibling, child or friend. Through systematic research, the IBR team developed a screening process to identify the best way to rehabilitate drug users who end up in jail or prison.
The TCU Drug Screen is a five- to 10-minute assessment used by workers in the criminal justice system to determine the severity of drug use. Questions include, “Did you get sick or have withdrawal when you quit or missed taking a drug?” and “How often did you inject drugs with a needle?”
“We developed this screening instrument because a number of prisons didn't have a standardized approach,” Simpson explained. “Most substance abusers who take the test qualify for treatment, but the test helps sort them out on the basis of severity. For those who don’t need high-intensity treatment, they can go to a less intensive option within the general prison population.”
Those with more severe problems can go to stand-alone facilities that emphasize building a therapeutic community where a user can feel safe and focus on therapy. There are fewer fights, fewer injuries, and security costs are much lower. Still, Simpson said, stand-alone programs are “a hard sell” in prisons.
In the early 1990s, Texas embarked on an ambitious initiative to offer treatment for drug offenders. Over the years, however, lawmakers whittled away funding.
“Texas was really the first state to begin serious treatment efforts of the institutionalized,” Simpson said. “And even with all the funding cuts, Texas still has one of the largest prison treatment programs in the country.”
With billions of dollars pumped into the prison system each year, one of IBR’s crucial tasks is to provide the science to justify paying for treatment.
“Our models help people understand that evidence shows this stuff works — works,” Simpson said. “We use evidence-based practices, and our research shows that recidivism is higher for people who didn’t get help.”
Even those fortunate enough to receive treatment while incarcerated need support after release. “After they leave prison, if you don’t continue their care, then the effectiveness of treatment is lost. Retention is important, and the transition phase is crucial. We look at how to connect and fund these intervention plans. The issue is to find ways to get people in — whether it’s in a facility like a halfway house or follow-up counseling.”
Simpson’s team understands that funding is always part of the equation, whether it’s used to develop cost-effective methods of treatment or analyze the “real” cost of not treating an offender.
“Our first agenda item is to break the connection between drugs and crime,” Simpson said. “Apart from helping people psychologically, we know that getting crime rates down politically drives the system and sustains funding. But as a person interested in helping people heal and recover, that’s only a piece of what we really want to do.”
MANY OF THE drug users encountered by IBR staff never learned to handle the responsibilities of life. Drugs have been their coping mechanism, and treatment involves relearning essential life skills.
“It’s not just a matter of rehabilitation,” Simpson said. “Many of these people need ‘habilitation.’ Much of our material teaches social skills, parenting and basic communication. It is an uphill battle to draw people back into life. Drugs just feel good.”
They understand drug addiction is not a purely medical problem.
“Treatment is not a magic bullet. We can’t cure them with a pill. Recovery requires behavioral changes. It is more difficult to help people change their behavior if you don’t use a cognitive approach.”
Maturity and development essentially suspend when a person begins using drugs. IBR’s programs help addicts develop social skills and contain their emotional pain without drugs.
One IBR program helps two generations at once. Developed for drug-dependent mothers seeking treatment at a Fort Worth shelter, the Partners in Parenting program now includes a manual for counselors with materials and instructions for leading an eight-session workshop for clients. The workshop addresses needs such as developmental awareness, communication skills, guidance techniques and positive discipline strategies.
Many of the substance abusers exposed to IBR’s models begin treatment begrudgingly. Some are sentenced to treatment through a drug court. Others arrive through the traditional pathways in the criminal justice system. Motivation is a challenge.
“Many enter treatment angry and resentful, sometimes battling with self-reproach and depression — factors obviously at odds with having the mental energy needed to make the most of treatment offerings,” Simpson said.
IBR’s Cognitive Enhancements for Treatment of Probationers team develops motivational tools to encourage participation.
One of those tools, called Downward Spiral, is a board game for a half-dozen players who assume the roles of people who continue to abuse drugs and alcohol. Players move through the game by rolling dice and drawing “chance” cards — real-life situations designed to shine a light on the health, family, legal, social and mental consequences of substance abuse.
Another game-like tool, Under Construction, helps clients reach their goals. Participants build a “Tower of Strengths” by selecting cards that describe current strengths and strengths they hope to have one day. A worksheet helps them visualize how to apply their strengths to help solve a problem in their life.
Other programs use guided imagery to help clients learn how to master relaxation and focusing techniques.
The popular Viewpoint game promotes cooperation with peers through a problem-solving activity. Players get a deck of cards with descriptions of problems and another deck with items that could help solve those problems. The players take turns discussing how to solve the problems with the tools they’re given. Flexible thinking and cooperation help win the game.
“Our programs are developed through methodical research,” Simpson said. “We have conducted many large-scale evaluations, and they show that treatment can work.”
Over the last five years, IBR began focusing on how to get all of its precious research to the counselors on the front line.
“We realized that we can’t just announce an effective program. We have to work to transfer science to services. We take what we’ve learned and get programs to own it.”
Much of Simpson’s recent efforts center on organizational structure and how to penetrate old patterns among clinicians so that they embrace new ideas.
“We have to make sure it fits within their values and is easy to use,” he said. “Many of these practitioners are overworked and underfunded. The dropout rate is among the highest because wages are low, frustration is high. They are working with a tough population, almost the worst-case scenario.”
SIMPSON IS ALWAYS mindful that while finding solutions to drug addiction is at the heart of this work, science is the root.
“There is a strong demand for evidence-based practices these days,” noted Simpson, “from funding sources and programs alike, so we work hard on the science and on keeping our contributions visible in the literature. NIDA’s role is policy. My role is to provide them with science that says here are some proven ways to monitor and advance drug treatment services in this country.”
When Simpson is not giving a keynote speech at a national conference or traveling the globe to spread the drug treatment gospel, he happily plugs away in his office.
“It’s very nice to be at a private university with the freedom to pursue this valuable research,” he said. “Here at TCU, I’m appreciated, and I’ve not found a place I’d rather be.”
IBR’s programs reach much farther than Texas. Practitioners around the country use them, and the institute recently delved into a major project in England. Eleven specialists with the National Treatment Agency for Substance Misuse (NTA) in Great Britain trained with Simpson’s group at TCU last spring.
Some 300,000 people in England and Wales suffer from serious drug problems generally related to heroin and cocaine use. The country faces issues similar to those in the United States — the economic, social, health and crime-related problems of drug abusers and their families.
Peter Martin, CEO of Addaction, a leading private nonprofit provider of treatment services in the United Kingdom and a member of the delegation that visited IBR in March, said the assistance is sorely needed.
“With TCU’s support we have a far better chance of delivering real health and social gains to clients across the UK,” he said. “For me, this is probably the most important strategic initiative of its day for the sector.”
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