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Drug treatment providers' organizational responses to implementation of California's Proposition 36

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Drug treatment providers' organizational responses to implementation of California's Proposition 36

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Content DRUG TREATMENT PROVIDERS' ORGANIZATIONAL
RESPONSES TO IMPLEMENTATION
OF CALIFORNIA'S PROPOSITION 36
by
Grace Lynn Reynolds-Fisher
A Dissertation Presented to the
FACULTY OF THE SCHOOL OF POLICY, PLANNING,
AND DEVELOPMENT
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PUBLIC ADMINISTRATION
August 2004
Copyright 2004 Grace Lynn Reynolds-Fisher
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UMI Number: 3145270
Copyright 2004 by
Reynolds-Fisher, Grace Lynn
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Acknowledgements
This dissertation represents the attempt to conceptualize and
measure the effects of implementation of a large-scale statewide program
remanding non-violent drug offenders into drug treatment rather than
prison or jail. The research grew out of the opportunity provided by the
passage of legislation known as Proposition 36.
In the completion of this research I wish to acknowledge my
appreciation for the support of my dissertation committee, Professors
Howard Greenwald, R. Ross Clayton, and Chester Newland. Whatever
faults remain in the work are all mine. For those that were avoided or
rectified, I owe much to these three mentors.
To Professor Greenwald I am indebted for advice and help that
made this research possible. To Professor Clayton I am indebted for
positive and cheerful feedback during all phases of the research. To
Professor Newland I am indebted for promptness and clarity in the
execution of this manuscript. I am also indebted to Professor Robert
Myrtle, whose doctoral seminar in organizational theory provided much
of the underpinnings of this research.
For the support provided in conducting this research, I also wish to
express my appreciation to the Center for Behavioral Research and
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Services at the California State University, Long Beach, which provided
much in the way of logistical support. I also wish to thank Peter Mendivil,
Alison Arevalo, and Jesus Castrejon for valuable assistance they rendered
during the course of the research.
I also wish to thank all of the drug treatment programs that agreed
to be interviewed for this research. I could not have accomplished this
project without their willingness to extend themselves on my behalf.
Finally, for providing unusual support, understanding, and
encouragement, I wish to express my appreciation and love to my
husband, Dennis.
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Table of Contents
Acknowledgements ................................................................................. ii
List of T ables............................................................................................vi
List of Figures........................................................................................ viii
A bstract..................................................................................................... xi
CHAPTER
1. Statement of the Problem and Conceptual Approach...............1
a. Organization of the Dissertation ..................................6
2. Organizational Theory Applied to the Study of Drug
Treatment and the Implementation of Proposition 36 ......... 8
a. What is Proposition 36? ...................................................8
i. How Proposition 36 Works .............................. 13
ii. The Basis of Proposition 36 ................................ 14
b. Review of the Literature ................................................ 16
i. Drug Abuse and Crime ..................................... 16
ii. History of Compulsory Drug T reatm ent.......... 18
iii. Drug C ourts...........................................................21
iv. Voluntary Versus Coerced Treatm ent...............25
c. Conceptual Framework .................................................. 27
i. Isomorphism and Proposition 3 6 .......................32
ii. Open Systems Theory and Proposition 36 ... 33
iii. Values and Proposition 3 6 .................................. 36
iv. Resource Dependence Theory and
Proposition 3 6 ..................................................... 41
v. Summary of the Conceptual Fram ew ork..........48
3. Phase I - In-Depth Qualitative Interview s...............................50
a. Instrum entation................................................................ 50
i. Piloting the Q uestionnaire................................... 51
ii. V ariab les............................................................................57
b. Sampling ........................................................................... 60
c. H ypotheses........................................................................ 61
d. A nalyses.............................................................................68
4. Phase I - Results of the Qualitative Interview s....................... 75
iv
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a. Hypothesis 1 .......................................................................75
b. Hypothesis 2 .......................................................................80
c. Hypothesis 3 ........................................................................90
d. Hypothesis 4 .......................................................................95
e. Hypothesis 5 .................................................................. 104
f. Hypothesis 6 .................................................................... 109
g. Other Findings..................................................................I l l
h. Summary of the Findings from Phase I .........................126
5. Phase II - Telephone Interview s............................................... 133
a. Instrum entation................................................................ 134
b. Sam pling............................................................................ 140
c. H ypotheses........................................................................ 143
d. Data A nalyses....................................................................147
e. R esults................................................................................ 152
6. Conclusions and Discussion........................................................ 188
a. Directions for Future Research....................................... 199
b. Limitations of the S tu d y .................................................. 203
c. Alternative Approaches and Theoretical M odels 208
Literature C ited ..........................................................................................211
A ppendices.................................................................................................223
v
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List of Tables (continued)
Table 16. Final Regression Model Predicting Overall
Experience with Proposition 3 6 ..................................... 174
Table 17. Correlation Matrix: Compliance and Resistance
Activities and Funding Concerns Variables................ 178
Table 18. Correlation Matrix: Compliance and Resistance
Activities and Program Value Variables........................ 180
v ii
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List of Tables
Table 1. Orange County Participating Drug
Treatment Program s........................................................56
Table 2. Los Angeles County Participating Drug
Treatment Program s......................................................... 56
Table 3. Coding Schema by Q uestion....................................................69
Table 4. Coding Schema by H ypothesis................................................71
Table 5. Coding Schema by T opic.......................................................... 73
Table 6. Number and Type of New Hires by Program .......................85
Table 7. Compliance and Resistance Activities Identified
In Phase I Interview s......................................................... 131
Table 8. Translating Phase I Findings into Telephone
Survey Item s..................................................................... 138
Table 9. Telephone Interview Respondents by C ounty...................... 142
Table 10. Hypotheses, Indicators, and Statistical T ests....................... 149
Table 11. Telephone Interviews: Participating Programs
By Year and T y p e...............................................................154
Table 12. Telephone Interview Results: Compliance
And Resistance Activities................................................. 159
Table 13. Summary Statistics on All Variables.................................. 160
Table 14. Correlation Matrix: Compliance and Resistance
V ariab les..........................................................................................170
Table 15. Preliminary Regression Results Predicting
Overall Proposition 36 Experience................................ 172
vi
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List of Figures
Figure 1. Proposition 36 Theoretical Framework
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Abstract
The Substance Abuse and Crime Prevention Act (SACPA), also
known as Proposition 36, was implemented statewide in California
beginning in July 2001. This legislation remands first-time drug users to
drug treatment rather than to prison or jail, and was funded for a five-
year period at an annual cost of $120 million per year.
The focus of this research is the implementation of Proposition 36
by the drug treatment programs funded to provide Proposition 36
services. The theoretical framework incorporates ideas of isomorphic
influences within organizational fields, resource dependence theory, and
the role of values. This theoretical framework leads to testable
hypotheses regarding organizational responses to the implementation of
Proposition 36.
The research was undertaken in two phases. Phase I of the
research consisted of structured interviews with key informants from 42
drug treatment programs in Los Angeles and Orange counties. Phase I
of the research tested six hypotheses with respect to drug treatment
program actions during Proposition 36 implementation. Five
compliance activities and one resistance activity were identified. Phase
II of the research involved structured telephone interviews with a
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purposive sample of 72 drug treatment programs in six Southern
California counties (Los Angeles, Orange, Kern, San Bernardino,
Riverside and Santa Barbara). Chi-square analysis was used to explore
associations between the type of drug treatment provider (outpatient
compared to residential) with respect to the compliance and resistance
activities identified from the Phase I interviews. A linear regression
model was developed that used a dependent variable capturing overall
experience with Proposition 36. The final model included three
compliance variables (sharing problems and solutions with other
treatment providers, hiring new staff, acquiring additional space
through rental or purchase) that were most predictive of the programs'
overall experience with Proposition 36. This model accounted for 22%
of the variance. The resistance activity was not significant in the
multivariate model.
The implications of these findings in the context of organizational
compliance and resistance activities are discussed. Future directions for
research, including an exploration of the centralized assessment
procedures implemented as part of Proposition 36, and its impact on
organizational resistance, are also discussed.
x
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Chapter 1
Statement of the Problem and Conceptual Approach
In November 2000, California voters approved Proposition 36, the
"Substance Abuse and Crime Prevention Act of 2000 (SACPA)." This
measure marked major changes to the state law so that adult offenders
who use or possess illegal drugs receive treatment rather than
incarceration or probation with treatment. The measure also provides
$120 million annually to pay for the treatment programs. Passage of this
proposition is having a tremendous effect on drug treatment programs in
California, and the outcome of this social experiment could have far
reaching impacts on drug treatment nationally. This policy has presented
an opportunity for research to contribute to an understanding of how the
implementation of a statewide program affects major aspects of drug
treatment. To this end, this study has been designed and implemented to
develop understandings of how the drug treatment system in the counties
of Southern California adapted to implement Proposition 36.
Initiatives in states other than California have been adopted or
proposed to reduce the number of drug users who receive prison rather
than treatment. A rizona passed Proposition 200 in 1996, but its program
is extremely small compared to California's Proposition 36. There has also
been an active system of drug courts in place around the country, with
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estimates that almost 700 drug courts were active in the United States by
2000 (Goldkamp, White, & Robinson, 2001).
The theoretical framework of this research is taken from Aldrich's
evolutionary model (1999; 1979). In that model, organizations are
theorized to change over time, either intentionally or unintentionally, as
they react to shifts in the broader system in which they are a part. In
addition, this research draws on theory from Thompson (1967) concerning
the technical core of an organization; Katz and Kahn (1978) with respect to
their definition of functional categories for organizational classification,
especially maintenance organizations with respect to open systems theory;
and from Scott (1998) and Pfeffer and Salancik (1978) on resource
dependence theory.
Thompson (1967), Oliver (1991), and Scott (1998) all theorize that
organizations will differentially moderate the influence that the
environment has on organizational functioning. Thompson (1967) states
that, "under norms of rationality, organizations seek to seal off their core
technologies from environmental influences" (1967; p. 19). Oliver
describes the strategies employed by organizations faced with
environm ental influences as acquiescence, com prom ise, avoidance,
defiance, and manipulation (cited in Scott, 1998; p. 212).
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In this context, this research identifies compliance and resistance
activities, undertaken by drug treatment programs in response to
Proposition 36 implementation. Compliance and resistance activities are
seen to be integral parts of organizational functioning at both the micro
(individual) and macro (organizational) levels. This follows Wicks
typology of compliance and resistance as "behavioral responses to
constraining elements of structure (Wicks, 1998)."
This research was done in two phases. Phase I entails open-ended
interviews with drug treatment program staff to attempt to assess how the
drug treatment programs responded to the implementation of Proposition
36. What did they do initially and what problems did they encounter?
Implementation required that drug treatment programs that met the
requirements for state licensing actively initiate a request for funding from
the counties by responding to the request for proposals issued for
Proposition 36 treatment providers. Once funded, programs had to
follow county guidelines and contractual obligations. These included but
were not limited to use of a shared computer system for tracking
participants across probation, the courts and treatment programs,
including obtaining or upgrading existing com puters; in those counties
without a county-implemented data system, programs had to develop and
implement internal methods of tracking clients for recordkeeping.
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Programs had to ensure that their treatment practices and guidelines were
consistent with county and state requirements, including the mandated
length of stay guidelines. When these practices were not consistent, they
had to change their internal treatment guidelines to make them consistent
with state and county requirements. Programs also had to train their
staffs on Proposition 36 requirements and procedures; in those counties
with shared data systems, programs had to see to it that their staffs
received adequate training on the computer databases in use by the
counties. In some cases, programs had to hire new staff, or increase the
workloads of existing staff.
Implementation of Proposition 36 is also related to the extent to
which Proposition 36 is congruent (a) with the philosophy of the drug
treatment program 's mission; (b) with the drug treatment program's
treatment philosophy; and (c) with the staffs' personal treatment values
and orientation.
Programs may have found they needed to educate staffs on the
merits of legally coerced participation in treatment; to provide their staffs
with education and experience in dealing with a criminal justice-involved
clientele if they w ere not already serving this population; and to educate
their staffs on the internal changes to drug treatment guidelines being
imposed by the county as a requirement of contracts. Former treatment
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guidelines may have been very different from the treatment guidelines
required for Proposition 36.
The National Institute on Drug Abuse (NIDA) held a forum in
Riverside, California, in the fall of 2000 to solicit proposals from
researchers for the study of Proposition 36. At that time, NIDA staff
presented possible scenarios for how drug treatment providers would
react to implementation of the legislation. In addition to the needs listed
above, they thought that drug treatment providers could possibly react to
implementation of Proposition 36 in ways that would have a negative
effect both on staff and on clients coming into the program. For example,
despite the provision of new funding to cover the costs of Proposition 36,
it was hypothesized that, if the funding was not sufficient to meet the
demand for treatment, drug treatment providers would be forced to
increase case loads of counseling and case management staff, possibly
resulting in burnout and other negative consequences. Increasing
caseloads of existing staff without hiring additional people to shoulder the
burden of the increased case loads resulting from Proposition 36 could, in
turn, negatively affect client outcomes, as staff would be unable to provide
sufficient attention to clients due to their overburdened schedules. These
were just some of the concerns voiced at this meeting with NIDA staff
(Hilton, 2000).
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However, the bottom line was that no one really knew how drug
treatment providers would react to implementation of Proposition 36, its
impact on drug treatment staff, its impact on treatment practices, or its
impact on drug treatment clients and outcomes.
Organization of the Dissertation
The dissertation is organized into six chapters. The first chapter
provides a statement of the problem addressed in this research. Chapter
Two provides the background for the research. Description of Proposition
36 provisions is presented first. Those are then placed in the context, both
historical and philosophical, of legally coerced drug treatment. Next is a
review of the organizational behavior literature as it relates to drug
treatment programs with particular emphasis on open systems theory and
resource dependence theory to formulate hypotheses of how drug
treatment programs would be expected to behave within the
implementation of this new legislative program.
Chapter Three discusses the method used in Phase I of the research
which was in-depth, semi-structured interviews with drug treatment staff.
This chapter covers the instrumentation, sampling frame, hypotheses, and
the analytical m ethods used for analyzing the qualitative data. Chapter
Four discusses the findings from these in-depth, semi-structured
interviews with respect to the hypotheses.
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Chapter Five discusses Phase II of the research, which involved
telephone interviews with drug treatment programs in Southern
California counties to see whether the data gathered from the in-depth
interviews could be used to develop quantitative interview questions for
purposes of determining the generalizability of the findings from Phase I.
This chapter discusses the instrumentation, presents the sampling frame,
reviews the hypotheses that are being tested, and discusses the analytical
methods that are used on the data from the telephone interviews. The
results of the telephone survey are then presented.
Finally, Chapter Six provides the conclusions and discussion of the
findings from both phases of the research, including an overview of the
results, limitations of the study, alternative explanations for the findings,
alternative theoretical approaches that could have been used in exploring
how drug treatment programs would respond to implementation of
Proposition 36, and some implications of the current study for policy and
practice and for future research.
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Chapter 2
Organizational Theory Applied to the Study of Drug Treatment and the
Implementation of Proposition 36
a. The Legislation: What is Proposition 36?
The Substance Abuse and Crime Prevention Act of 2000, also
known as Proposition 36, is legislation that took effect in California on
July 1, 2001. Under this legislation, an offender convicted of a nonviolent
drug possession offense could be sentenced to probation with drug
treatment. In other words, it would divert eligible offenders from prison,
jail, and non-treatment probation sentences to probation with treatment.
Individuals would be ineligible for this treatment and probation option if
they had a previous conviction for a felony, a concurrent conviction for a
felony other than a non-violent drug possession offense, or a concurrent
conviction for a misdemeanor not related to the use of drugs.
The California Legislative Analyst's Office (LAO) conducted an
evaluation of Proposition 36's impact on the state's drug treatment
infrastructure, as required by law prior to the vote (Legislative Analyst's
Office, 2000). According to LAO estimates, approximately 36,000
individuals in California w ho w ould have been incarcerated for drug
possession would be diverted from prisons and jails (Riley, Ebener,
Chiesa, Turner, & Ringel, 2000). Two scenarios were estimated: a high
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treatment intensity scenario and a low treatment intensity scenario. Under
the first scenario, 71% of these 36,000 individuals would be diverted to
outpatient treatment, 26% would be diverted to long-term residential care,
and 3% would be diverted to short-term inpatient treatment. The total
cost of this scenario was projected to be $114.4 million per year. Under
the second scenario, 65% of individuals would go into outpatient
treatment, 22% would go into long-term residential care, 7% would go
into day programs, 4% would go into methadone maintenance, and 2%
would go into short-term inpatient treatment. This scenario was
estimated to cost $92.4 million. These estimates were taken from data
from the California Alcohol and Drug Data System (CADDS). The LAO
office believed that the estimate of 36,000 individuals diverted into the
drug treatment system was conservative because these numbers "do not
contain estimates of the number of misdemeanants who formerly would
have received probation only, but under Proposition 36 would be eligible
for probation with treatment" (p. 21) (Riley et al., 2000). No reliable
numbers existed at the time the study was done from which to draw
estimates of the size of this population.
The impact of Proposition 36 on drug treatment programs was
originally projected to be large. Using data from the Uniform Facility
Data Set (UFDS), which is a survey of substance abuse treatment
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facilities in California, existing treatment facilities are operating at or near
capacity (Riley et al., 2000). Residential treatment programs have 87% of
beds being utilized, and approximately 60% of these facilities maintain a
waiting list, with the average waiting list containing 23 people (p. 18)
(Riley et al., 2000). "A 1999 report from the California LAO found that
treatment capacity in California is insufficient; it found that waiting lists
understate actual demand for treatment and that the system is under
funded by about $330 million" (p. 18) (Riley et al., 2000). Based on the
preliminary allocation of Proposition 36 funds to the counties for fiscal
year 2001-2002, Los Angeles County ranked #1 in total allocation at
$30,330,454; San Diego County ranked #2 at $8,752,016; and Orange
County ranked #3 at $7,688,696. Allocations to counties are based on a
formula that includes the projected Proposition 36 caseload.
Los Angeles and Orange Counties are the first and second largest
counties by population in California (approximately 9.5 and 2.8 million
respectively according to the 2000 Census). In addition to the large
difference in total population, the two counties vary dramatically in their
overall class, race, and ethnic makeup. As an example, only 47.9% of
hou sing units in Los Angeles C ounty are ow ner occupied versus 61.4% in
Orange County. Percent Black in Los Angeles County is 9.8%, while
Orange County's Black population makes up 1.7% of the total
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population (United State Census Bureau, 2000). Similarly, the percentage
reporting Hispanic/Latino ethnicity was higher in Los Angeles County
(44.6%) than in Orange County (30.6%). The overall difference in the size
of the populations of the two counties has had an impact on the number of
people entering Prop 36 drug treatment programs. It was believed that
9,629 and 2,437 new participants would enter the Proposition 36 system
during the first year, respectively, in Los Angeles and Orange County
(these numbers are estimates based on the total state budget expenditure
and in relation to the total 36,000 estimated new participants statewide).
While Los Angeles County is about 3 times larger than Orange County, it
was estimated that it would serve approximately 4 times as many new
participants entering its Proposition 36 drug treatment programs after the
first year of implementation. This may be a reflection, in part, of the
overall demographic differences between the two counties, particularly
the levels of poverty as represented in the overall housing statistics. This
also means that Los Angeles County has received a much larger
Proposition 36 budget, approximately $30 million in relation to Orange
County, which received $7 million in 2001.
Reports from the Los A ngeles C ounty D epartm ent of A lcohol and
Drug Programs, and the Drug Policy Institute reveal some of the activity
during the first year of Proposition 36. Most of the focus of these
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reports has been on the types of individuals being remanded into
treatment under Proposition 36. The UCLA Integrated Substance Abuse
Programs (ISAP) is the statewide evaluator for Proposition 36. Results
from the statewide evaluation for Los Angeles County indicate that the
majority of offenders being remanded under Proposition 36 were
methamphetamine users, followed by crack and cocaine users (Alcohol
and Drug Programs, 2004). This is true for the state of California as a
whole (State of California Department of Alcohol and Drug Programs,
2002). The first Annual Report to the Legislature on Proposition 36 also
indicated that more than 30,000 drug offenders had been referred to
treatment in its first year of implementation and that for more than half of
them, Proposition 36 was providing their first experience of drug
treatment (State of California Department of Alcohol and Drug Programs,
2002). The Drug Policy Institute reported that treatment slots in California
increased by 68 percent during the first year of Proposition 36, but the
majority of these slots were for lower level outpatient treatment. The state
of California also reported that treatment capacity had expanded as a
result of Proposition 36. There was an increase of 42 percent in the overall
num ber of licensed program s statew ide, w ith certified residential
programs increasing by 17 percent and certified outpatient programs
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increasing by 81 percent (State of California Department of Alcohol and
Drug Programs, 2002).
i. How Proposition 36 Works
While some variation exists across the counties as to how
Proposition 36 works, the State of California Alcohol and Drug Programs
provided a framework for implementation that was adopted by most of
the counties. This flow chart can be found in the Appendix.
The District Attorney determines eligibility for Proposition 36
sentencing before a defendant enters his or her plea before the Superior
Court. After eligibility is determined as a condition of probation, clients
within each county take slightly different pathways toward their
treatment programs. In Los Angeles County, Proposition 36 participants
are required to report to one of the 11 Community Assessment Service
Centers (CASCs) located throughout the Department of Health Services'
(DHS) 8 Service Planning Areas (SPAs). CASCs are private organizations
contracted with the DHS Alcohol and Drug Program Administration
(ADPA) to provide addiction screening and treatment referrals as well as
to provide links to a host of human and social services.
A D ep uty Probation Officer (DPO) is co-located at each CASC to
provide participants with a full orientation of the terms and conditions of
probation. CASC personnel administer the Addiction Severity Index
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(ASI) (McLellan, Luborsky, Cacciola, Griffith, & McGahan, 1985) to each
participant and refer the participant to an ADPA— contracted treatment
provider where access to the level of treatment services and other human
services is provided.
In Orange County, on the other hand, Proposition 36 participants
first report to the County Probation office for an orientation to the terms
and conditions of their probation, after which they are referred to the
Orange County Health Care Agency (HCA) for ASI assessment. HCA
Alcohol and Drug Abuse Services (ADAS) staff place participants in
ADAS contracted treatment programs. At the time of ASI assessment,
ADAS staff also assesses participants for any other health or human
services needs and refer the participants to relevant County agencies.
ii. The Basis of Proposition 36
The National Institute on Drug Abuse (NIDA) published
"Principles of Drug Addiction Treatment" (National Institute on Drug
Abuse, 1999) outlining 13 principles of effective drug abuse treatment.
These principles are derived from many years of drug treatment research
and many of them have been incorporated into the state guidelines that
cover m anagem ent of drug offenders arrested under Proposition 36.
These 13 NIDA principles are: "1. No single treatment is appropriate for
all individuals; 2. Treatment needs to be readily available; 3. Effective
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treatment attends to the multiple needs of the individual; 4. An
individual's treatment and service plan must be assessed continually and
modified as necessary to ensure that the plan meet's the person's
changing needs; 5. Remaining in treatment for an adequate period of time
is critical for treatment effectiveness; 6. Counseling (individual and/or
group) and other behavioral therapies are critical components of effective
treatment for addiction; 7. Medications are an important element of
treatment for many patients, especially when combined with counseling
and other behavioral therapies; 8. Addicted or drug-abusing individuals
with coexisting mental disorders should have both disorders treated in an
integrated way; 9. Medical detoxification is only the first stage of
addiction treatment and by itself does little to change long-term drug use;
10. Treatment does not need to be voluntary to be effective; 11. Possible
drug use during treatment must be monitored continuously, as lapses to
drug use can occur during treatment; 12. Treatment programs should
provide assessments for HIV/AIDS, hepatitis B and C, tuberculosis and
other infectious diseases, and counseling to help patients modify or
change behaviors that place themselves or others at risk of infection; 13.
R ecovery from drug addiction can be a long-term process and frequently
requires multiple episodes of treatment" (National Institute on Drug
Abuse, 1999).
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These 13 principles have been incorporated into the treatment
prescribed for each of the three levels of assessment under the Proposition
36 framework. Length of stay is an important component of Proposition
36, with minimum lengths of stay being required for each of the three
levels of treatment. All individuals receiving treatment under Proposition
36 must have an individualized treatment plan developed in conjunction
with their case manager; they must participate in individual and group
counseling sessions and attend a specified number of 12-step meetings
each week. They must receive referrals to additional services they may
need, and they must be randomly tested for drug use during their stay in
treatment. Opiate addicted individuals are to receive opiate-replacement
therapy, especially if they have a documented history of unsuccessful
prior attempts at drug treatment. The minimum level of services
prescribed under Proposition 36 for Los Angeles County for each of the
three treatment levels can be found in the appendix.
b. Review of the Literature
i. Drug Abuse and Crime
Many studies have demonstrated the relationship between illicit
drug use and crime. Inciardi and Pottieger, in a review of 20 years of
literature on crime and drug use, found that self-reported crimes among
drug users far exceeded the number of crimes for which they were
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arrested or convicted (Inciardi & Pottieger, 1998). The types of crimes
engaged in by drug users include prostitution, robbery, burglary, assault,
drug sales, shoplifting, forgery, fraud, and extortion (Inciardi & Pottieger,
1998). Reasons for the connection between drug use and crime include
simple "drugs cause crime" typologies to more complex frameworks that
identify pharmacological effects of drugs on behavior (which may lead to
violent an d /o r criminal acts); the economic demands imposed by the need
to obtain funds to purchase expensive illegal drugs; and the systematic
exposure to criminal subcultures associated with drug use (Faupel, 1988;
French, Zarkin, Hubbard, & Rachal, 1991,1993; Inciardi & Pottieger, 1998).
Other researchers view drugs and crime from an ecological
perspective, noting that social marginalization and poverty are always
found in proximity to drug use and criminal activity (Inciardi, McBride, &
Rivers, 1996). Within the context of drug abuse treatment, reductions in
criminal activity have been noted as one positive outcome of drug
treatment for both female (Daley et al., 2001) and male drug users (Anglin
& McGlothlin, 1984; Hubbard, Rachal, Craddock, & Cavanaugh, 1984).
Illicit drug possession, by itself, is also a crime in most states. Proponents
of Proposition 36 v iew m andated treatm ent as a m ore hum ane approach
to drug addiction than arrest and imprisonment.
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ii. History of Compulsory Drug Treatment
Compulsory treatment of drug offenders is not new. One of the
first such programs was operated by the Public Health Service hospitals in
Lexington, Kentucky (opened in 1935) and in Fort Worth, Texas, opened a
few years later (Maddux, 1988). Program outcomes were mixed, or
disappointing, depending on whether data were for the voluntarily or
involuntarily committed (Inciardi, 1988; Maddux, 1988). Individuals
treated under legal coercion had better outcomes than others during the
period from about 1943 through 1960 (Maddux, 1988). With the
enactment of the Narcotic Addict Rehabilitation Act (NARA) in 1966, the
hospitals at Lexington and Fort W orth began admitting NARA patients in
1967 (Maddux, 1988). Several outcome studies were conducted on NARA
patients, with most finding some evidence of reduced use of opiates
(Maddux, 1988). However, the outcome most widely used in these studies
has been total, long-term abstinence, which is "a severe outcome measure"
(p. 45) and one that was seldom met (Maddux, 1988).
In California, the Civil Addict Program was established as a civil
commitment program in 1961. The intent of the legislation was to provide
non-punitive treatm ent as w ell as control of drug offenders "for the
protection of the public" (McGlothlin, Anglin, & Wilson, 1977a) (p. 5). It
grew out of California's successful experience with nalorphine (Nalline)
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testing and a controlled parole experiment conducted by the California
Department of Corrections in the late 1950s (Anglin, 1988; McGlothlin et
al., 1977a; McGlothlin, Anglin, & Wilson, 1977b).
Individuals remanded to the civil addict program were committed
for a period of seven years for felony and misdemeanor convictions.
Individuals could be released earlier than seven years if they were drug-
free for three consecutive years and otherwise complied with the
conditions of their commitment (McGlothlin et al., 1977a). Several
evaluations of the civil addict program were published on cohorts of
individuals who entered the program between 1962-1975 (Anglin, 1988;
Anglin, Almog, Fisher, & Peters, 1989; Anglin & McGlothlin, 1984;
McGlothlin et al., 1977a). Findings of the several studies on the civil
addict program cohorts were generally favorable, with individuals
participating in the program having lower levels of detected drug use on
routine urine tests, lower percentages of time spent incarcerated after
completing treatment, lower daily drug use after treatment, and less time
spent in illegal activities post-treatment (Anglin, 1988; McGlothlin et al.,
1977a).
F ollow ing California's success w ith the civil addict program
described above, New York made a similar attempt in 1966 with a
program operated by the state's Narcotic Addiction Control
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Commission (NACC). This program was a failure, for a number of
reasons, including its program structure of institutional commitment
followed by community aftercare, its choice of buildings which had
formerly been medium and maximum security prisons as rehabilitation
centers, and its use of untrained staff (Inciardi, 1988).
The Treatment Outcome Prospective Study (TOPS) reviewed data
from drug-addicted individuals referred to drug treatment through the
criminal justice system under the Treatment Alternatives to Street Crime
(TASC) programs (Cook & Weinman, 1988; Hubbard, Collins, Rachal, &
Cavanaugh, 1988; Inciardi et al., 1996). TASC programs are federally
funded, but locally administered, programs that link drug treatment
programs and the criminal justice system (Inciardi et al., 1996). The TOPS
study was able to compare TASC clients to other (non-TASC) criminally
involved clients and to clients with no criminal justice system
involvement, in both inpatient and outpatient treatment modalities
(Hubbard et al., 1988). Results of the TOPS study indicated that treatment
itself reduced crime, but there was no appreciable difference between the
TASC clients and the clients with no criminal justice involvement at the
tim e of treatm ent on this m easure (Hubbard et al., 1988).
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iii. Drug Courts
In 1989, five dedicated drug courts were convened in the United
States to create collaborative partnerships between the judicial system and
local drug treatment providers. The first five courts were in Miami (Dade
County), Florida; Oakland (Alameda County), California; Fort Lauderdale
(Broward County), Florida; Phoenix (Maricopa County) Arizona; and
Portland (Multnomah County), Oregon (Inciardi et al., 1996; Terry, 1999).
Common characteristics of these drug courts included eligibility
restrictions to nonviolent offenders, supervised mandatory drug
treatment, frequent contact with judges or other court personnel through
regularly scheduled status hearings, and frequent, mandatory drug
testing (United States General Accounting Office, 1997). Two approaches
are generally used to process cases in drug courts: diversion or deferred
prosecution, and post adjudication (United States General Accounting
Office, 1997). Under deferred prosecution, defendants waive their right to
a speedy trial and enter drug treatment. Completion of drug treatment
then results in either no further prosecution for the original crimes, or
dismissal of charges. Under the post adjudication approach, defendants
are charged and tried. If convicted, their sentences are suspended,
pending completion of drug treatment. Failure to complete drug
treatment, or completion of treatment, then affects sentencing,
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providing an incentive towards rehabilitation (United States General
Accounting Office, 1997).
The Center for Substance Abuse Treatment (CSAT) has provided
guidelines to drug courts which include screening, assessment,
comprehensive, client-oriented treatment, therapeutic relapse prevention
techniques, and case management of the clients' performance as integral
parts of drug treatment (U. S. Department of Health and Human Services,
1997; United States General Accounting Office, 1997).
The number of drug courts since 1989 has increased dramatically,
with some authors estimating that 700 were in operation nationwide
(Goldkamp et al., 2001). Several studies of the effectiveness of the drug
courts have been undertaken (Brewster, 2001; Cresswell & Deschenes,
2001; Goldkamp et al., 2001; Inciardi et al., 1996; Miller & Shutt, 2001;
Secrest & Shicor, 2001; Spohn, Piper, Martin, & Frenzel, 2001; United
States General Accounting Office, 1997; Wolf & Colyer, 2001). An
evaluation of drug courts in Portland and Las Vegas found that
aggregated data on individual outcomes across several years of data were
generally positive, but differences were found depending on
im plem entation specifics of the program s across several years and cohorts
(Goldkamp et al., 2001). Enrollee failure rates of up to 90% were found in
the South Carolina drug court study, which investigated factors related
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to drug court failure, such as crack-cocaine use and minority race (Miller
& Shutt, 2001).
In a study of the drug court of Orange County, California,
researchers found many differences in perceptions of the drug court
experience between minority and non-minority participants, but no
differences in outcomes (Cresswell & Deschenes, 2001). In the Chester
County, Pennsylvania, drug court program, African-American
participants were found to do poorly, compared to other participants
(Brewster, 2001). However, the Chester County drug court study found a
lower level of drug use as indicated by positive urine tests in drug court
participants and a lower rate of re-arrests (Brewster, 2001).
Using offender recidivism as an outcome measure, researchers also
found lower rates of re-arrest among drug court participants in the
Douglas County (Omaha), Nebraska, drug-court (Spohn et al., 2001). In
Riverside County, California, the drug court program achieved program
completion rates of 56.9% with their first cohort, and most of the removals
from the program were due to continuous substance abuse (Secrest &
Shicor, 2001). A study of drug court participants in New York State
explored the types of problem s encountered by drug court participants,
including problems with their physical health, problems with their
personal social environment, and problems with the larger social
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structure (Wolf & Colyer, 2001). Given the strict requirements imposed on
drug court participants with respect to attendance at mandatory drug
treatment sessions, as well as regularly scheduled court appearances, such
barriers were found to affect participants' likelihood of completing the
drug court program (Wolf & Colyer, 2001).
These findings were echoed in the CSAT report on the 1999
National Drug Court Treatment Survey (Peyton & Grossweiler, 2001).
This survey found that 64% of drug courts indicated that "missed too
many treatment appointments" was a legitimate reason for discharge
from the drug court program, and 47% indicated that it was one of the top
three reasons for discharge (Peyton & Grossweiler, 2001). The United
States General Accounting Office reviewed 20 studies of drug court
programs and also conducted a survey of 134 of the 140 drug courts in
operation in 1997 (United States General Accounting Office, 1997). GAO
was not able to come to firm conclusions regarding the drug courts based
on the review of the 20 studies, citing differences in methodologies, and a
lack of follow-up data on drug court participants once they left the
program (United States General Accounting Office, 1997). The survey
revealed that com pletion rates ranged from 8% (Baltimore, M D) to 95%
(Rochester, NY).
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Retention rates ranged from 32% (Visalia, CA) to 100% (Warrenton,
NC) (U. S. Department of Health and Human Services, 1997).
In California, under Prop 36, several counties, including Los
Angeles County and Orange County, are using existing drug court
infrastructure in the implementation of Proposition 36 activities.
However, Proposition 36 activities are not limited to the drug courts.
iv. Voluntary Versus Coerced Treatment
The length of stay in drug treatment has been demonstrated to be
one of the most consistent predictors of individual outcomes (Daley et al.,
2001; Nurco, Kinlock, & Hanlon, 1994; Richard, Montoya, Nelson, &
Spence, 1995; Simpson, Joe, & Rowan-Szal, 1997). Patient and program
characteristics have also been demonstrated to have an impact on
outcomes (Aszalos, McDuff, Weintraub, Montoya, & Schwartz, 1999;
Broome, Simpson, & Joe, 1999; Grella, Annon, & Anglin, 1995; Hiller,
Broome, Knight, & Simpson, 2000; Joe, Simpson, & Broome, 1998,1999;
Prendergast, Podus, & McCormack, 1998). Patient characteristics have
also been associated with entry into treatment (Bell, Montoya, Richard, &
Dayton, 1998) and retention in treatment (Fisher, Lankford, & Galea, 1996;
M ertens & W eisner, 2000). Positive outcom es of drug treatm ent include
increased employment (DeAngelis, McCaslin, & Ungerleider, 1978; French
et al., 1991,1993), reduced use of opiates (Anglin, 1988; Anglin &
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Fisher, 1987; Hser, Anglin, & Chou, 1988), reduced use of speedball
(Grella, Anglin, & Wugalter, 1997), reductions in criminal activity (Anglin
& McGlothlin, 1984; Daley et a l, 2000; French et al., 1993; Harwood,
Hubbard, Collins, & Tims, 1988; Hubbard et al., 1984) and reductions in
HIV/AIDS risk behaviors (Prendergast, Urada, & Podus, 2001) such as
needle sharing (Grella & Anglin, 1995; Grella, Anglin, & Annon, 1996;
Grella et al., 1995; Longshore, Hsieh, Danila, & Anglin, 1993; Woods et al.,
1989; Woods et al., 1991; Woods et al., 1999) and high-risk sexual
behaviors (Grella et al., 1996; Grella et al., 1995; Hser, Grella, Chou, &
Anglin, 1998; Longshore & Hsieh, 1998; Longshore, Hsieh, & Anglin,
1994). Drug abuse treatment has also been shown to be effective with
drug users who are already HIV infected (Batki & London, 1991; McCarty,
LaPrade, & Botticelli, 1996).
The literature on the effectiveness of drug treatment is very
extensive, covering decades of research (Prendergast et al., 1998). An
important dimension to drug abuse treatment, in addition to those noted,
is legally coerced entry into substance abuse treatment. Many studies
have indicated that individuals legally coerced or remanded into
treatm ent have better outcom es than individuals w ithout crim inal justice
incentives to complete treatment (Anglin, 1988; Brewster, 2001; Goldkamp
et al., 2001; McGlothlin et al., 1977a, 1977b; Spohn et al., 2001). Other
26
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studies have found that legally coerced participants in drug abuse
treatment do no worse than other drug treatment participants (Brecht,
Anglin, & Wang, 1993; Farabee, Prendergast, & Anglin, 1998; Hubbard et
al., 1984; Hubbard et al., 1988). Program implementation characteristics
have been found to play a large role in legally mandated drug treatment
programs that do not have positive outcomes for clients (Inciardi, 1988).
c. Conceptual Framework
The impact of Proposition 36 is being felt at the organizational level
by drug treatment programs. Aldrich has developed a typology for
understanding the impact of political processes and events that affect
organizations and populations of organizations (Aldrich, 1999).
Proposition 36 is a type of "direct government support" in that it is a
policy that enhances legitimacy, stimulates demand, or provides a direct
subsidy to a population of organizations. The potential impact of
Proposition 36, given the estimates of approximately 36,000 additional
individuals coming into California drug treatment programs as a
consequence of implementation, can hypothetically take several forms
(Riley et al., 2000). Potential reactions include increasing caseloads of
existing staff, hiring additional staff, adding treatm ent slots to existing
programs, an d /o r opening additional treatment facilities. The supply of
drug treatment slots within California has increased quickly under
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Proposition 36 and one of the side effects of this has been to put pressure
on drug treatment programs due to need to hire and train new staff,
obtain licensure from the state, and to follow through on construction and
remodeling for the creation of new treatment facilities. According to the
State of California Drug and Alcohol Programs, available treatment slots
increased 68 percent statewide in the first year of Proposition 36,
indicating a fairly quick ramping up of treatment capacity (State of
California Department of Alcohol and Drug Programs, 2002). However,
this increase includes outpatient programs that are not of high intensity
and suitable only for those offenders who do not have long-term
addiction problems.
Given the impact that drug treatment program characteristics can
have on client outcomes (Broome et al., 1999), the reaction of programs to
Proposition 36 will directly impact assessments of whether diversion of
drug offenders from prison to treatment produces the desired positive
effects. Simpson and colleagues have advocated learning what goes on
inside drug treatment programs to better understand the process of drug
treatment; this should lead to a better understanding of how programs
can be effective (D. Sim pson et al., 1997; Sim pson, 2001; Sim pson, Joe,
Rowan-Szal, & Greener, 1997). Schmidt and Weisner (1999) have
advocated using multi-level analysis when evaluating drug treatment
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access and utilization, including individual level, organizational level, and
societal level parameters. Other authors have noted that program changes
and public policy changes can affect the course of individual addiction
and treatment careers (Hser, Anglin, Grella, Longshore, & Prendergast,
1997; Hser et al., 1998).
The conceptual framework for this research can be seen in Figure 1.
Drug treatment programs exist in a larger environment consisting of other
drug treatment programs and other organizational actors. Any drug
treatment program is hypothesized to be influenced by three things: 1.
Isomorphic influences that are shared and exchanged with other drug
treatment providers; 2. Values internal to the organization and its internal
organizational actors, such as staff and management; and 3. Resources
within the environment directed toward the funding of drug treatment
activities, and those activities that are ancillary to drug treatment. All of
these elements of the drug treatment program confront Proposition 36,
which is itself a collection of isomorphic practices, values and resources.
Once the drug treatment program made the decision to accept
Proposition 36 funding, it fell under the obligation to conform to
Proposition 36 standards, both as they are prom ulgated in the legislation
and interpreted and operationalized in the contracts established by each
County. However, as organizational actors, drug treatment programs
29
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may resist certain aspects of Proposition 36 an d /o r comply with its
aspects. Some aspects of Proposition 36 may be viewed by the
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Proposition 36 Theoretical
Framework
Open Systems
Framework
Overall
Experience
Values
Drug
Treatment
Programs
Compliance Resistance
Isomorphism
Resource
Dependence and
Availability
Proposition 36
Requirements
Figure 1. The conceptual framework of
Proposition 36, indicating the influence of
compliance and resistance activities on
overall experience within an open system s
framework.
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organization as something that can be adapted without change or effort.
Other aspects of Proposition 36 may require that the drug treatment
program resist some or all of it. Some of these resistance and compliance
actions may be overt on the part of the drug treatment program, and some
may not. The actual mix of resistance and compliance any one drug
treatment program will decide upon will depend upon that program's
current mix of isomorphic practices, values and need for the resources
offered as part of participation in Proposition 36.
Proposition 36 is not a monolithic entity. As new legislation, its
implementation was in flux, and certainly during the early months and
years of the program it changed as the need for changes arose. Over time,
some stasis occurred as programs came into compliance, or programs
negotiated those things that they initially resisted; some programs opted
out of Proposition 36 totally, finding it incompatible with their program
activities.
i. Isomorphism and Proposition 36
Scott (1998; 2000) and Meyer and Rowan (1977) have noted that
organizations adapt to their environment through the adoption of internal
structures or technologies consistent w ith other influential actors w ithin
their environment. This creates isomorphism across organizations and
organizational fields (Aldrich, 1999). According to Aldrich,
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populations of organizations share many things, including routines and
competencies, cooperative alliances, and avenues for collective action
(Aldrich, 1999). While drug treatment programs share routines and
competencies because they provide relatively similar services to relatively
similar clients, much variation between individual drug treatment
programs, even those offering services in the same treatment modality,
have been reported. For example, a study of Massachusetts detoxification
programs showed that there was minimal variation in the mean length of
stay among heroin, alcohol, and cocaine users admitted for treatment, but
significant variation among sites. The researchers concluded that the
variation among the sites was attributable to "system" rather than
individual characteristics (McCarty, 1997). Program structure and content
has been found to affect client retention in treatment across a number of
studies (Fisher et al., 1996; Hoffman et al., 1994; Szuster, Rich, Chung, &
Bisconer, 1996).
ii. Open Systems Theory and Proposition 36
This research builds on two aspects of organizations: the first
focuses on the relationship of the organization to its environment,
especially w ith respect to organizational responses to environm ental
change, open systems theory, and resource dependence; the second
focuses on the congruence between the organization's values and
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external environmental factors. The relationship that an organization has
to its larger environment, and the impact that environment can have on
any organizations' operations comes out of the larger open systems
theory. According to Scott (1998), the open systems perspective on
organizations differs from the rational system and the natural systems
approach in acknowledging that organizations are not "sealed off from
their environments, but are open to and dependent on flows of personnel,
resources, and information from outside" (p. 27). His definition of an
organization from the open systems perspective is that "organizations are
systems of interdependent activities linking shifting coalitions of
participants; the systems are embedded in—dependent on continuing
exchanges with and constituted by—the environments in which they
operate" (p. 28).
Thompson, in Organizations in Action (1967), states that open
systems theory delineates an organization that "contains more variables
than we can comprehend at one time," (p. 6) and that some of these
variables cannot be predicted, controlled or easily understood. Like Scott,
he views the complex organization as a set of parts that work together.
U sing this approach, the "survival of the system is taken to be the goal
and the parts and their relationships are determined through evolutionary
process" (p. 6). Organizations conceptualized as open systems are
34
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governed by "homeostasis, or self-stabilization ... [which] keeps the
system viable in the face of disturbances stemming from the environment"
(p. 7).
Katz and Kahn (1978) provide an overview of past research on
organizations and their environment, recounting the studies done by
Burns and Stalker (1961) and Lawrence and Lorsch (1967). Lawrence and
Lorsch focused on the formal structure adopted by the organization as a
direct result of changes in the external environment. "Lawrence and
Lorsch proposed a contingency theory of organizational structure,
namely, that the effective organization is the one that parallels in its own
departments the characteristics of the most relevant sector of their
respective environments" (Katz & Kahn, 1978; p. 135).
Researchers have found that organizational and environmental
factors, rather than specific needs of clients, determine the extent to which
ancillary services for medical care or mental health services are available
in any given drug treatment program (D'Aunno & Price, 1985; Etheridge,
Craddock, Dunteman, & Hubbard, 1995). In the instance of the research
noted above, it was the publicly funded compared to the privately funded
distinction in drug treatm ent program s that explained differences in the
availability of these services to clients. The drug treatment programs
responded to environmental pressures differently, choosing to do
35
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business in either the non-profit or the for-profit arena, depending on
decisions made within the organization as the best way to respond to
environmental pressures regarding funding and resources. Because
organizations are subject to these environmental factors, organizations
will either conform to the environmental influence, or attempt to fend it
off (Hannon & Freeman, 1984; Scott, 2000).
iii. Values and Proposition 36
Whether an organization adapts to or resists a given environmental
influence is dependent upon a number of factors, one of which is the
extent to which the outside influence is congruent with organizational
goals and values. The literature on congruence in organizational studies
covers a wide range of topics, but for purposes of this research, initial
stress is on congruence between organizational goals and values from the
perspective of the 'maintenance organization.' According to Katz and
Kahn (1978), if organizations are considered to be a subsystem of the
larger society, the activities of organizations fall into four functional
categories: productive, maintenance, adaptive, and managerial/political.
Drug abuse treatment organizations are categorized as maintenance
organizations, broadly defined as organizations that are "devoted to the
socialization of people for their roles in other organizations and the larger
society" (p. 145). Katz and Kahn note a subdivision of activities within
36
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this category, of the direct function of maintenance, as in education and
training; and the restorative function, "as in health and welfare activities
and institutions of reform and rehabilitation" (p. 145).
Maintenance organizations face special challenges as organizations
in several respects. First, roles are not as clearly defined within such
organizations, because they are concerned with changing people, not the
transformation of raw materials into finished products. "The role of
teacher or of the therapist could be heavily proscribed if one were
concerned only with the technical aspects of learning ... [however] a
wider discretionary power is necessary for the staff member in the
maintenance organization. This makes possible an optimum interaction
between pupil and teacher, and between patient and therapist" (p. 159).
Second, maintenance organizations face problems "with respect to
the hierarchical separation of power, privilege, and reward, in that there is
likely to be a cleavage between the staff and population of subjects to be
taught or treated. This line, moreover, is between the authority to make
organizational decisions and the requirement to submit to them; to have a
fair degree of autonomy in working out one's role and to be assigned
specific directives about one's conduct; to adm inister sanctions and
receive punishments; to enjoy privileges and to be deprived of them" (p.
165). Because maintenance organizations face these dual challenges,
37
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most research has been undertaken between the organizational values and
the congruence between these values and the values of individuals and
groups within the organization (Boxx & Odom, 1991; Vancourver,
Millsap, & Peters, 1994); the congruence of values between co-workers
(Adkins & Ravlin, 1996), between supervisors and employees (Witt, 1998),
and the fit of the organization's culture to the organization's explicitly
stated goals (Harris & Mossholder, 1996).
Nadler and Tushman (1988) provide another model of
organizations based on a systems perspective. According to their
framework, all parts of an organization, subparts and components, must
be managed and structured in such a way that they achieve a state of
congruence. In an applied study of organizational goal congruence and
organizational effectiveness in mental health programs, Scheid and
Greenley (1997) examined two levels of congruence, institutional
conformity (program objectives meet the demands of external
constituents) and goal congruence (program objectives meet the
expectations of external constituents). These researchers found that a
higher degree of specialization facilitates higher levels of goal congruence
and perceived effectiveness. G eneralist organizations, w hile offering
more diverse services and serving more diverse client populations, had
lower levels of both goal congruence and perceived effectiveness.
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While organizations adapt structures, they also adapt technologies,
and this argument can be made for the "maintenance" type of
organization as well as the production type. These technologies
(Thompson, 1967) include the hardware used to perform the tasks
(physical plant, computer hardware), the skills and knowledge of the
organization's employees, and the inputs or objects on which the
organization performs its work. The main component of technology is the
core technology, meaning a central set of tasks around which the
organization is built (Thompson, 1967). For drug abuse treatment
programs, the core technology is a therapeutic process.
The nature of the therapeutic process depends on the particular
treatment modality and philosophy underlying the core technology (i.e.,
the treatment process). In drug treatment, values of the organization are
embodied in the counseling staff who perform the core functions; these
values may differ across programs, as there are many models of drug
treatment, with underlying conceptual frameworks, some value driven,
some science driven, and some an amalgam of both (Maisto & Connors,
1988).
H ealth services delivery system s, in general, and drug treatm ent
programs in particular, are comprised of indeterminate technologies
(processes) that do not allow for the precise measurement of means and
39
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ends (Shortell, 1996). "Belief systems about what constitutes 'good'
medicine or 'good' care have been propagated by the health professionals
that are based on health practices and experience of caregivers"
(McCaughrin, 1991). These belief systems, in turn, have a powerful
influence on the technical core (in this case, the treatment delivery
system).
In this respect, implementation of Proposition 36 goes directly to
the technical core of drug treatment programs, first, by providing direct
support for increasing the number of inputs (people/clients/patients) in
the therapeutic process. However, the values inherent in Proposition 36,
that is, treatment rather than prison, also directly affect the technical core
of drug treatment programs. In many treatment modalities (therapeutic
communities, the Alcoholics Anonymous/Narcotics Anonymous model),
punitive measures are taken against the recovering addicts as part of the
therapeutic process. To the extent that the underlying philosophy of
Proposition 36 is treatment oriented, it may be congruent with a drug
treatment program 's treatment philosophy, and therefore congruent with
prevailing treatment program values. On the other hand, as Proposition
36 did not initially support som e of the generally accepted accountability
measures routinely employed by treatment programs to assess client
conformance to treatment or standards requiring complete abstinence
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from substance use while in treatment, (generally through routine urine
testing for signs of drug abuse), it may be in direct or indirect conflict with
other values embraced by the treatment program as it may be perceived
as representing a more permissive treatment philosophy. Bigelow and
Stone found that values of the staff employed by nonprofit community
health centers were often at odds with the requirements of the funding
agencies (Bigelow & Stone, 1995). "A center's dominant coalition often
embodies a range of values, not just managerial ones and its willingness to
conform to funder requirements is tempered by these values ... [one
consequence of] compliance may destabilize the relationship between the
community health center and key external groups other than the funder ...
" (p. 3) (Bigelow & Stone, 1995). The role of resource dependence is
discussed below.
iv. Resource Dependence Theory and Proposition 36
Resource dependence theory has many proponents, including
Thompson, and Salancik and Pfeffer. This theory maintains that the
environment is a critical factor in the structure and behavior of
organizations as the environment is a source of great uncertainty for
organizations (D avis & Powell, 1992). D espite uncertainty, organizations
must have exchange transactions with their environment because no
organization is entirely self-sufficient with respect to inputs. According
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to Pfeffer and Salancik, dependence upon the environment for resources
causes the organization to be constrained by its environment, and by
understanding the relationship between an organization and its
environment, one can make predictions about organizational behavior
(Pfeffer & Salancik, 1978). According to Pfeffer and Salancik:
The three most elemental structural characteristics of environments
are concentration, the extent to which power and authority in the
environment is widely dispersed; munificence, or the availability
or scarcity of critical resources; and interconnectedness, the number
and pattern of linkages, or connections, among organizations.
Because of the characteristics of the environment, organizations, according
to Pfeffer and Salancik (and others, such as Thompson and later, Scott) can
respond in two main ways: either they can comply and adapt to the
restraints placed upon them by the environment, or organizations can
resist environmental influences either by avoidance or management of the
environment (1978). However, ultimately, Pfeffer and Salancik state that
organizations "are willing to bear the costs of restricted discretion for the
benefits of predictable and certain exchanges (p. 183)."
There have been several criticisms of resource dependence theory,
especially with respect to its underlying assumption that organizations
have an alm ost infinite capacity to adapt to changing environm ents, and
that organizations, in their adaptations, are rational. Stinchcombe
(Stinchcombe, 1965) noted that organizational structures are
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"imprinted" on an organization at its inception and are difficult to change.
Hannan and Freeman (Hannon & Freeman, 1984) also theorize "structural
inertia" for most organizations, noting that most organizations cannot
reorganize themselves faster than the environment within which they
operate is changing. In this way, organizations face constraints, not only
externally from their environment, but internally, from their own
structures. A tension results from these internally and externally
generated constraints upon an organization (Hannan & Freeman, 1977).
Hannan and Freeman summarize these constraints as follows. Internal
constraints are generated by "an organization's investment in plant,
equipment, and specialized personnel assets"; constraints on decision
makers' information; internal political constraints such that "when
organizations alter structure, political equilibria are disturbed..." and
constraints "generated by their own history." External constraints
include: "legal and fiscal barriers to entry and exit from markets";
external constraints upon information; "legitimacy constraints ... any
legitimacy an organization has been able to generate constitutes an asset
...so legitimacy considerations tend to limit adaptation ... "; and "collective
rationality ... w e cannot presum e that a course of action that is adaptive
for a single organization facing some changing environment will be
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adaptive for many competing organizations adopting a similar strategy"
(Hannon & Freeman, 1996).
Organizations are dependent upon their environments for three
things: material resources, including "monetary and hum an resources";
information; and legitimacy, in the form of social and political support
(Jun & Armstrong, 1997). "Organizations are consumers of environmental
resources. They are also part of a larger social system, which subjects
them to external influences. Because organizations draw needed
resources from the environment, they must justify their existence and
operation. Organizations need social and political support from their
environment to guarantee continued receipt of environmental resources"
(p. 107) (Jun & Armstrong, 1997). Unlike theories of bureaucracy, in
which staff and employees are viewed as organizational actors who are
loyal to their organization, resource dependence theory views
organizational actors as forming coalitions and breaking up coalitions as
their needs and the political and social environment within the
organization changes. Under this type of organizational environment,
when disagreement occurs between organizational actors, the power of
the various actors determ ines the outcom e of the conflict, after follow ing
the organizational decision-making process. Generally, the organizational
actor with the greatest power will prevail when conflict emerges within
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an organizational environment under resource dependence theory (Pfeffer
& Salancik, 1974).
A distinction is made within drug treatment programs between
those that serve private clients and those that serve public clients. Private
clients tend to be middle class and to have some form of healthcare
insurance to offset the costs of treatment. Public clients "by contrast, tend
to be indigent, often with criminal records" (p. 65) (Smith & Lipsky, 1993).
These publicly served clients tend to be treated in outpatient programs,
the majority of which are run by nonprofit organizations. In 1987, "four-
fifths of the $800 million that went to serve 650,000 clients in drug
treatment nationwide came from public sources, including government
contracts and Medicaid reimbursement, with the states carrying most of
the funding burden" (p. 65) (Smith & Lipsky, 1993).
Two dimensions of legitimacy must be considered when discussing
the relationship between government funding sources and nonprofit
organizations that receive that funding. The first is the legitimacy that is
conferred on the nonprofit organization when they are the recipients of
state or federal funding. Saidel (1991), in her investigation of the
relationships b etw een the state agency that funds N ew York state
nonprofits, and the nonprofit agencies that receive state funding, found
that state funding provided several things beyond simply dollars to the
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agencies (Saidel, 1991). "The arts council is in the forefront of any one of
our funders. Also, their seal of approval helps leverage other private and
public funds" (p. 5). State funding was also perceived as stable and
reliable according to nonprofit agencies, a quality they found attractive
over and above the actual dollar amount of the funding from the state.
"It's not so much the quantity but what they give for it and the reliability
of the funding."
Saidel (1991) found that there was reciprocity between the state
agencies and the nonprofit agencies that made the relationship of value to
the state agencies as well as to the nonprofit organizations. "Political
support and legitimacy are included as resources because of the public
arena in which resource relationships between the state agencies and
nonprofit organizations are forged. In their dealings with the legislature,
governor's office, and division of the budget, nonprofit organizations can
be influential actors on behalf of the interests of state agencies" (Saidel,
1991). Bielefeld (Bielefeld, 1992) also found that most nonprofits deliver
the types of services that, because of the way funding flows from
governmental entities to fund those services, "[they] are often forced into
the public policy process in order to influence the flow of those
resources" (cited in (Heimovics, Herman, & Coughlin, 1993).
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Froelich further explored the resource dependence environment of
nonprofit organizations (Froelich, 1999). Given the inherent uncertainties
in the organizational environment regarding resources, many nonprofits
have opted for a strategy that includes diversification of funding and
revenue. Nonprofits will have shifting dependence on several sources of
funding, including governmental contracts, private contributions, and
commercial activities. "Commercial activities" cover a wide range of
revenue-raising activities in this context, including selling products to
customers, or charging fees for program services that may have been
previously delivered free of charge to the client. As such, however,
"increasing reliance on program service fees or other types of commercial
activity is accompanied by anxiety and criticism as sector observers and
participants anticipate its potential negative influence on organizational
actors and their missions" (p. 2) (Froelich, 1999).
Increasing reliance on revenue from program fees has also followed
declines in governmental funding. In 1974, government funding
accounted for approximately 46 percent of funding of United Way
agencies. Estimates for 1980 place this percent of funding at around 34
percent, and estim ates for 1986 put it at around 27 percent. There has
been a little fluctuation in this percentage as programs have recovered a
little of the ground lost under the Reagan administration (estimates for
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1996 put the percent of funding from the government for the nonprofit
sector at around 32 percent, up from the 27 percent estimate for 1986) but
overall, the nonprofit sector has seen its percent of revenue from the
government declining steadily since the 1970s (Froelich, 1999).
This same pattern of decreases in government funding, especially
federal funding, has been apparent for drug treatment programs.
According to Smith and Lipsky (Smith & Lipsky, 1993), "public and
private spending on drug treatment programs is only just beginning to
approach the level of 1976 spending in real terms. Total spending in 1987
dollars fell from $1.5 billion in 1976 to $1.3 billion in 1987 ... federal
spending for drug treatment as a percent of total public and private
revenues dropped from 42.5 percent in 1976 to 19.5 percent in 1987" (p.
64) (Smith & Lipsky, 1993).
v. Summary of the Conceptual Framework
A drug treatment program 's experience with Proposition 36 is
hypothesized to depend on: 1) the practices and competencies it uses in its
daily effort to provide the services it identifies as drug abuse treatment
services, and which it has learned or borrowed from other similar
organizational actors through isom orphism ; 2) the values held by the
program and its staff, and embodied in its approach to drug treatment
and its expectations of its clients and staff; and 3) the resources it has to
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support its function of providing drug treatment services, including
resources that it obtains from the environment by entering into a
contractual relationship with one of the counties for Proposition 36
funding. This framework is illustrated in Figure 1.
In its own right, Proposition 36 is also comprised of isomorphic
influences, values, and resources. Within an open-systems framework, the
drug treatment providers and Proposition 36 confront each other within
the environment. Treatment programs may either resist or comply with
the requirements of Proposition 36. Proposition 36, as it is refined
through feedback received from the providers, will also change until a
balance is struck between the needs of the drug treatment providers and
the mandates of Proposition 36.
In the next chapter, this conceptual framework will be
operationalized and tested to determine if drug treatment providers
involved in the implementation of Proposition 36 behaved in accordance
with the theories presented here.
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Chapter 3
In-Depth Qualitative Interviews
In order to investigate the drug treatment programs' behavior
during implementation of Proposition 36, a series of interviews were
conducted in Los Angeles County and Orange County. Programs that
agreed to participate in the interviews were located as far north in Los
Angeles County as Pasadena, and as far south into Orange County as San
Clemente. Interviews were conducted with key informants, individuals
identified in each drug treatment program as being familiar with
Proposition 36 implementation in their program.
a. Instrumentation
A semi-structured questionnaire was constructed based on six pre
specified hypotheses. These hypotheses are derived from organizational
theory related to how drug treatment programs might be expected to
respond to Proposition 36 in its many facets. These included an influx of
funding into the drug treatment program population and a set of values of
which treatment providers would either approve of or disapprove.
Responses were hypothesized to derive from a number of factors,
including the drug treatm ent program 's prior experience w ith criminal-
justice-involved clients; the program 's organizational structure, which is
related to the organization's size in terms of the number of individuals
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it employs and the number of clients it has a capacity to serve. This is also
related to the type of program it is, whether residential, outpatient or
both. Another hypothesis is related to the extent to which the program
actively sought out, or participated in training on Proposition 36. Values
inherent in Proposition 36 and how those values meshed with the values
of the drug treatment providers were also hypothesized to affect the
program 's experience of Proposition 36 implementation, as well as
defining and determining the extent to which the treatment modalities
espoused by Proposition 36 were reflective of what the program already
had in place; and finally, staff perceptions of clients coming into the
program as Proposition 36 clients was theorized to affect the program's
responses to the implementation. The final questionnaire had a total of 26
questions and is included in the appendix.
i. Piloting the Questionnaire
The questionnaire was piloted twice, once at a residential drug
treatment program in Los Angeles County and again at a residential
treatment program in Orange County, before being finalized for use in
both counties. Los Angeles and Orange counties were chosen due to the
large am ount of Proposition 36 funding they received from the state, and
the fact that each county took a very different approach to Proposition 36.
Los Angeles County decentralized intake and assessment through the
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use of Community Assessment Centers (CASCs), and Orange County
highly centralized intakes, with all intakes and assessments being done by
the County through its Health Care Agency. The pilot testing made it
possible to determine not only whether the questions made sense to the
interviewees, but also whether they made sense in the context of each
county's implementation of Proposition 36. For each of the pilot
interviews, the interviews were tape recorded and transcribed. All
interviews were also timed, and it was determined that the interview took
approximately 20-30 minutes depending on the willingness of the
respondent to elaborate answers.
Determining the sample for each of the counties was done
differently due to differences in providing information about Proposition
36 providers in each county. For Orange County, the list of all drug
treatment providers was obtained from the State of California Alcohol and
Drug Programs website. This website provides the name, address, and
contact information for all drug treatment providers in the State of
California certified by the State to provide alcohol and drug treatment.
Orange County, at least at the time these interviews took place, did
not provide a w ebsite of its ow n listing Proposition 36 drug treatm ent
providers within the County. Each provider had to be called individually,
and from those telephone calls, it was determined whether the provider
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was currently under contract to the County to provide Proposition 36
services. All programs answering in the affirmative to telephone inquiries
about the provision of Proposition 36 services were added to the initial list
of Orange County providers from which the sample would be drawn for
interview.
Los Angeles County, in contrast to Orange County, provides an up-
to-date listing of all drug treatment providers under contract to the
County to provide Proposition 36 services. This list was obtained from
www.lapublichealth.org and the alphabetical list of providers was printed
off. This list was then used as the list from which the sample would be
drawn for interviews.
Each program on each of the county lists was numbered from 1 to
whatever the number of total programs on the list was. Using PROC Plan
in SAS software, a random number list was obtained. For Orange County,
15 interviews were to be done. Therefore, to allow for refusals and errors
in the listing, a list of 47 numbers was produced using PROC Plan.
Programs were then contacted through "cold calls" to inquire as to
whether their Proposition 36 coordinator was available. Once that
individual had been identified and contacted, he or she w as invited to
participate in the interview. Interviews were scheduled to take place on-
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site at the drug treatment program, at the respondent's convenience in
terms of day and time.
A similar procedure was used for the Los Angeles County
programs, although 25 interviews were done in Los Angeles County
because it is larger than Orange County and contains a much larger
number of drug treatment programs. The final sample consisted of 15
programs in Orange County, and 26 programs in Los Angeles County.
The order in which programs were interviewed was in the order of
random selection as much as possible. It is important to note that while
the programs were randomly selected from among all Proposition 36-
certified programs in the county, the person interviewed at each program
was not randomly selected from among all program staff. Once a
program had been randomly selected for an interview, the Proposition 36
Coordinator or other individual was selected as a key informant. In this
way, the sampling from among program staff was purposive in that an
attempt was made to interview a person who was knowledgeable about
Proposition 36 implementation within the program.
At least three attempts were made to reach either the Proposition
36 Coordinator or the Executive Director of each program selected. Once
contact had been made by telephone, each respondent was invited to
complete the face-to-face interview, which was conducted on site at the
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drug treatment program and required anywhere from 20 to 45 minutes to
complete. In some cases, more than one person was interviewed,
depending upon the wishes of the initial respondent. Usually, if two staff
members participated in the interview, the interview consisted of the
Executive Director (ED) and another staff person designated by the ED as
most knowledgeable about the Proposition 36 activities taking place
within the treatment program. A breakdown of participating programs
by county is provided below. The final interview instrument is included
in the appendix.
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Table 1. Orange County Participating Drug Treatment Programs (N= 15)
Modality Total (%)
Outpatient only 7(47)
Residential only 6(40)
Outpatient and residential 2(13)
Table 2. Los Angeles County Participating Drug Treatment Programs
(N =26)
Modality Total (%)
Outpatient only 10 (39)
Residential only 7(27)
Outpatient and residential 9 (34)
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The questionnaire was developed using inductive techniques
(Miles & Huberman, 1994). Possible responses of drug treatment
programs to Proposition 36 were considered and questions developed to
explore if these responses had, in fact, occurred. Questions were also
tailored so that responses not initially considered could come out in the
course of the interview.
ii. Variables
As programs chose to participate in Proposition 36 voluntarily by
responding to the county's Request for Applications (RFA), initial
preparation for Prop 36 is captured by the question, "When did you first
hear about Proposition 36 within the context of your job?
Participation in county-coordinated meetings is measured by a
question asking about meetings, extent of participation in those meetings
(how often, how many staff attended) and if any of them were noteworthy
for any reason, positive or negative.
The date the program received its first Proposition 36 client is
measured by a question about the approximate day or date the first
Proposition 36 client was admitted.
Staff concerns and values concerning Proposition 36 w as m easured
by the question, "Were there strong advocates either for or against
Proposition 36 as legislation within this treatment program?"
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The organizational structure the program has in place for
managing Proposition 36 is captured by the question, "What is the
organizational structure of the administrative staff, the director, and the
counselors who work with Proposition 36 clients?"
Total program staff is measured as a continuous numerical value.
The total number of program staff that work with the Proposition 36
contract and the total number of clients in the program are both captured
as continuous numerical values.
Total number of Proposition 36 beds (for residential programs) is
measured as a continuous numerical value.
Total number of Proposition 36 outpatient slots (for outpatient
programs) is measured as a continuous value.
The program 's initial experience with Proposition 36 is captured by
the question, "What were some of the characteristics of the Proposition 36
implementation at your treatment program?"
Hiring of new /additional staff is captured by the question, "Have
you hired new staff in order to assist with work on the Proposition 36
contract?" Programs responding in the affirmative were then asked what
types of staff positions (counselors, intake staff, adm inistrative staff) w ere
hired.
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The program 's response to the initial lack of funding for urine
testing captures how the program responded to this fiscal issue. The
original legislation did not contain a funding provision for urine testing
(in fact, it prohibited use of appropriated funds for urine testing) and
programs had to accommodate this in some way. After July 1,2002, or at
the start of the second year of Proposition 36 funding, the Governor of
California signed a separate authorization to use block grant funding to
pay for the urine testing of all Proposition 36 clients.
The types of drugs the program tested its clients for includes both the time
period before funding was available from the state block grant funds and
after the funds became available.
Initial experience of Proposition 36 clients is captured in a number
of ways. One question is, "What were the initial perceptions of the first
Proposition 36 clients that came through the program?" This attempts to
elicit the reactions of staff to the first clients coming through the program.
Another question, "What was their behavior in counseling sessions?" also
attempted to get at perceptions, and perhaps prejudices that may have
existed concerning those first clients referred through the Proposition 36
mechanism. Another question, "Was the perceived level of need of the
Proposition 36 clients different from other program clients?" attempts to
get the respondent to make a comparison between the program's
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"regular" clients and Proposition 36 clients to enumerate similarities and
differences.
"Were there other financial issues and concerns" elicits information
on financial concerns concerning the administration of the Proposition 36
contracts that were separate from the initial lack of funding for urine
testing. Anticipated responses concerned possible slow payment on the
part of the counties for invoices submitted for payment and sliding fee
scales for clients to pay something toward their treatment costs.
Relationships to other treatment providers and assessment centers
is elicited by several questions including, "Which CASC or assessment
center(s) do you receive clients from?" "What are the key components of
the relationship?" and "How does communication take place between the
program and the assessment center(s)?"
B. Participating Drug Treatment Programs— Sampling
This first phase of the research used 26 drug treatment programs in
Los Angeles County and 15 programs in Orange County. The programs
are broadly representative of the breakdown of treatment modalities
anticipated to be used under Proposition 36 according to the California
L egislative A nalyst's Office (Riley et al., 2000). That analysis em phasized
that the majority of offenders remanded into treatment under Proposition
36 would initially enter outpatient treatment modalities, followed by
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long-term inpatient, short-term inpatient, and methadone maintenance.
The sample of programs interviewed included both outpatient and
residential programs, including some providers that were large enough to
have both an outpatient and residential component to their treatment
programs. Neither in-patient programs nor methadone maintenance
programs were interviewed. The sample was purposive (Miles &
Huberman, 1994) in that all programs were located in the two largest
counties in California receiving Proposition 36 funding and comprised of
programs that were certified by their respective counties as eligible to
receive Proposition 36 clients on the date the legislation took effect. From
the programs meeting these criteria, a random sample was taken from
each county. After the programs were randomly selected, key informants
from each selected program were invited to participate in the interviews.
No limits were placed on the programs with respect to size or numbers of
clients served.
C. Hypotheses
The first phase of this research could be characterized as hypothesis
generating (Miles & Huberman, 1994). Grounded theory operates on the
assum ption that, w h en investigating n ew phenom ena, the investigator
should not make a prior commitment to a theoretical model, but instead,
should begin the investigation of the phenomena of interest through
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direct observation and collection of data. To facilitate the generation of
hypotheses for further exploration, qualitative or in-depth interviews
have been proposed as a method for obtaining information. Other
methodologies include ethnographies, participant observation and case
studies (Yin, 1994).
A qualitative method, employing a survey instrument using
structured, open-ended questions for the first phase, was selected for this
research. An objective was to generate hypotheses about how drug
treatment programs would respond to implementation of Proposition 36,
and to give drug treatment program staff the opportunity to describe in
their own words what happened within their organization and their own
reactions to what happened. However, the hypotheses listed below were
included at the outset because a wholly unknown phenomenon was not
being investigated, nor was the research being undertaken with a new
type of organization. Within the previous work of organizational
theorists, it was possible to provide some beginning hypotheses with
regards to the drug treatment providers' responses to Proposition 36. The
approach is not wholly phenomenological in this respect. The problem
w as approached from tw o perspectives: one, a sm all num ber of
hypotheses were pre-specified to be tested during the first phase of
interviews, and two, a methodology (the open-ended interview
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questions) was used that would allow for the generation of additional
hypotheses about the responses of drug treatment providers to
Proposition 36. Below a brief description of the previous organizational
theory that was the underpinning for each hypothesis is provided.
These pre-specified hypotheses are:
Hypothesis #1: Programs with prior experience with criminal
justice-involved clients will report a more positive experience with
Proposition 36 implementation than programs without such
experience. [Questions #5, 8,11,17,18 19].
The connection between drug use and criminal activity has been
well-established and some of this literature was reviewed earlier (Inciardi
& Pottieger, 1998; Prendergast et al., 1998). However, experience with
drug use and the criminal justice system on the part of clients does not
necessarily equate to a similar experience on the part of drug treatment
programs. Drug treatment programs could potentially choose to
participate in Proposition 36 for any number of reasons, including
increased legitimacy in the eyes of the county substance abuse
coordinating agencies, or internal pressures to participate in the new
funding stream.
D 'A unno and colleagues (1991) found that m any com m unity
mental health centers diversified into drug treatment provision, despite
the conflicts for the organization inherent in shifting from providing
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services from one type of clients to a broader range of clients with a
broader range of problems. It is possible that California drug treatment
providers might also, through the mechanism of Proposition 36, seek to
expand their clientele beyond those that they traditionally served. As
such, those drug treatment providers without substantial experience with
criminal justice-involved clients would face internal adjustments not faced
by drug treatment programs with prior experience.
Hypothesis #2: Programs with a clear organizational structure for
Proposition 36 clients and procedures will report a more positive
experience with implementation than those without such structure.
[Questions #1,2,3,5,6, 7,8,10,21,22,23,24].
James Thompson, in Organizations in Action, describes the structural
relationships among "production, personnel, supply and other service
units of the organization ... here efficiency is maximized by specializing
tasks and grouping them into departments, fixing responsibility according
to such principles as span of control or delegation, and controlling action
to plans" (p. 5). If drug treatment programs are structured for efficiency
of outcome, as theorists assume most organizations are, then having a
clear organizational structure should reduce the uncertainty associated
w ith im plem entation of a n ew program such as Proposition 36, and hence,
contribute to a positive experience on the part of the drug treatment
provider.
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Hypothesis #3: Frequency and intensity of the participation in
training provided by the counties will affect the programs'
experience in implementing Proposition 36. [Questions # 6 ,7 ,8 ,22,
2 6 ,2 7 ,28].
This is a complex hypothesis to test because it can be seen as
operating on two levels. The first level involves the training and
motivation of the individual worker. In changing environments, it is the
responsibility of management to ensure that workers have the skills
necessary to complete the tasks at hand. While many contemporary
authors have written on the importance and necessity of providing
employees with training, and upgrading training in the face of changing
expectations, this comes out of Henri Fayol's work on General Principles of
Management (Adkins & Ravlin, 1996). Training provides unity of
direction, that is, all the workers working toward the same end, or "the
same objective" (p. 56). At the organizational level, participation in
training on Proposition 36 provided by the counties is hypothesized to
occur through the open systems approach to organizations. As Thompson
states in one of his propositions "Under norms of rationality,
organizations seek to anticipate and adapt to environm ental changes
which cannot be buffered or leveled" (Thompson, 1967) (p. 21). Because
participation in Proposition 36 requires active participation on the part
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of the drug treatment programs, buffering activity has already been
dismissed as a possible strategy. Therefore, one of the adaptation
strategies would be to learn as much as possible about Proposition 36
from the counties. In this way, the environmental changes produced by
Proposition 36 could be anticipated and managed.
Hypothesis #4: The extent to which Proposition 36 (treatment
versus incarceration) reflects values already held by the
organization will affect implementation of Proposition 36.
[Questions # 2,4,9,11,13,29,30].
Hasenfeld (1992) notes that "another critical phenomenon in the
hum an service agency is the belief systems, ideologies, that drive the work
of professionals and, therefore, influence the operations of agencies" (p.
ix). Drug treatment programs, with their traditional reliance on 12-step
methods and other ideologies, rather than the adoption of new research
and technologies (Forman, Bovasso, & Woody, 2001) makes an
examination of the values and ideologies of the programs, and their
impact on implementation of a new program such as Proposition 36,
critical.
Hypothesis #5: The extent to which the treatment modalities
espoused by Proposition 36 are already incorporated into the drug
treatment program (12-step philosophy, group therapy orientation)
w ill affect the experience of Proposition 36 [Q uestions # 4, 9,10, 11,
12, 20, 25].
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This hypothesis is related to hypothesis 4 in that it focuses on the
values of the drug treatment program, as embodied in the specific drug
treatment the program provides. The extent to which Proposition 36's
requirements for client drug treatment are consistent with not only the
values, but the actual practices of the program, will influence the
experience of the program with Proposition 36 (Forman et al., 2001).
Hypothesis #6: Staff perceptions of the clients coming into the
program under Proposition 36 (compliant, difficult, more or less
needs than other clients) will affect the program 's experience with
Proposition 36 implementation. [Questions 11,12,14,15,16,17,19].
Hasenfeld (1992) describes the work of human services
organizations as deeply imbedded in the values of the employees who
provide the services. He quotes a study by Roth, completed in 1972 (p. 6)
in which the responsiveness of medical staff to patients in an emergency
room setting was dependent on the medical staff's assessment of the
patients "social worth" (p. 6) and their perceptions of who was a
"deserving patient." (p. 6). As Hasenfeld notes, "being perceived as
'deserving' [and appreciative]5 * ' may mean the difference between
receiving immediate assistance or being shunted through a bureaucratic
m aze" (p. 7). Based on this w ork, it w as hypothesized that staff
perceptions of the clients coming into the drug treatment programs
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through the mechanism of Proposition 36 would influence
implementation of Proposition 36.
D. Analysis
All of the interviews with drug treatment staff were tape-recorded
and the tapes were transcribed. In the few instances where the
respondent preferred not to be tape recorded, notes were taken during the
interview to record responses to each of the questions. Analysis was
performed using Nvivo qualitative software. Initially, all transcripts were
coded according to two coding schemes. The first simply identified each
block of text that was a response to the specific question on the open-
ended interview (1-26). All transcripts were thus coded to reflect specific
answers to the questions posed directly by the interviewer as responses
for each of the questions on the semi-structured interview guide. Two
coding categories were not tied to specific questions: Q-Background and
Q-Other. Q-Background included background questions asked about the
respondent at the end of the interview with respect to education level, job
title and number of years working in drug abuse treatment. Q-Other
included responses the respondent provided at the end of the interview
w hen asked if there w as any other com m ent h e /s h e w ish ed to m ake
concerning the implementation of Proposition 36.
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Table 3. Coding Schema by Question
Code Question
Q Other Other
Q Background Background
Q l
First context
Q2 Meeting
Q3 First client
Q4 Advocates
Q5 Org structure
Q6 New staff
Q 7
County role
Q8 CASC
Q9 Implementation
Q10 Initial decisions
Q ll Staffing decisions
Q12 Funding issues/urine testing
Q13 Current drug tests
Q14 Staff advocates
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Table 3. Coding Schema by Question (continued)
Code Question
Q15 Initial client perceptions
Q16 Behavior
Q17 Level of need
Q18 New skills
Q19 How acquire new skills
Q20 Other skills needed
Q21 Clarity of treatment standards
Q22 Other financial
Q23 Which Community Assessment Center (CASC)
Q24 CASC relationship
Q25 CASC communication
Q26 Treatment components/modalities
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Next, a set of first-level codes, usually a single item or word, was
constructed and each of the transcripts was coded accordingly based on
the specific hypotheses (1-6). The list of first-level codes is provided in
Table 4.
Table 4. Coding Schema by Hypothesis
Term Code Hypothesis
Criminal justice CJ
#1
Organization ORG #2
Training TRNG #3
Treatment values TXVAL #4
Treatment modalities TXMODS #5
Perception of Clients CLT #6
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For example, the printed transcripts of all the interviews were
reviewed by a textual analysis of responses to the specific question being
examined. For example: Did the program have previous experience
working with criminal justice involved clients? Microanalysis of the
transcripts in this way identified blocks of text in which the respondents'
answers to this specific question were identified. Subsequent textual
analysis was conducted using the first-level codes, that is, "criminal
justice" as a word string to pick up other references to working with
criminal justice involved clients not coming in direct response to the
question about it. These were the analysis methods used for all of the
hypotheses (hypothesis #1 through #6) regarding Proposition 36.
Once substantial textual analysis had been done on the topics of the
six prespecified hypotheses, the transcripts were analyzed according to
textual strings and recurrent word patterns on topics not prespecified by
the hypotheses.
Second level codes were based on items or themes that were
reoccurring on topics not already captured by either the coding of the
specific interview questions or the coding captured by the specific
hypotheses. M any w ere based on frequency of w ord count w ithin the
transcripts or on the total number of transcripts in which each topic
appeared. These second level codes are provided in Table 5.
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Table 5. Coding Schema by Topic
Topic Code
Addiction Severity Index ASI
Assessment/Reassessment ASSESS
Changes to Treatment TXCHG
Facilities FAC
No-Show Clients NOSHW
Central Assessment Centers CASCS
Values VAL
Pressures PRES
Schedule Changes SCHCHNG
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The process of coding qualitative data using a computer package
follows a familiar process that has been described elsewhere (Strauss &
Corbin, 1998). Briefly, an electronic container is created using the
software and the transcribed interview texts are copied or moved into that
container. In this case, the transcribed interviews originally saved as
Microsoft Word documents (*.doc files) were resaved as rich text format
files (*.rtf files) and imported into the electronic container created in
Nvivo software. The separate *.rtf files were combined into one project,
making it possible to code the text files, and later, to conduct text searches
as all of the interview transcripts were now viewable as one file, not as
separate documents. Coding was done by scrolling through the
documents and typing the codes where appropriate. Computerized
coding of this sort is not necessarily that different from manual coding, as
each line of text must be micro analyzed for content and evaluated for
proper coding. Once coding was complete, searches of the entire file,
based on the prespecified codes, was possible. After each text search, the
search results were saved as separate output files for later review.
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Chapter 4
Results of the Qualitative Interviews
The results of the key informant interviews, based on transcripts of
the semi-structured interviews, are excerpted below. Findings from the
interviews are organized according to pre-specified hypothesis.
Respondents are identified only by the type of program they were
employed by (outpatient, residential) and the county in which the
program was located.
A. Findings—Hypothesis #1
Hypothesis #1: Experience with criminal justice involved clients
will have an impact on the program's response to Prop 36.
For the majority of programs, previous work with criminal justice
involved clients was substantial. These clients comprised the bulk of the
program 's caseload, and adding Proposition 36 clients was not considered
to have made any significant impact on the program.
I think they fit in just fine. They just join the flow of what we've
already got. They don't stand out; they've got their criminal
histories just like anybody else. The only difference is that they are
under a different contract. They all have the same needs as every
other client that has a substance abuse problem. They fit in very
well. Very well. — Residential Los Angeles County Program
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We're very proficient at working with the criminal justice courts....
We were a little hesitant because we have not run an outpatient
program, per se. We ran a lot of counseling services, but not a
formal, you know, like — that had done outpatient counseling for
20 odd years, you know private outpatient. So we didn't know
what to expect and we felt a little unprepared. But when it actually
came around to providing the services, this program is looking a
lot like all the other court-mandated programs. -Orange County
Outpatient Program
Many programs experienced a difference between what they
originally anticipated or predicted Proposition 36 clients would be like,
and the reality of what they actually got. But for most programs, no major
adjustments were needed to work with these clients.
The initial clients who came into Prop 36 were predominantly fairly
hard-core, well known in the system of drug abusers. And the
reason being that many of these people had spent a lot of time in
jail, a lot of time in treatment in the past, and when Prop 36 was
implemented in the community, we picked up a whole group of
historically active users who were known well within the system,
but since Prop 36 was a new law and they had not broken that law
until just recently they never had access to this kind of program.
They always were put in jail or prison. Some of them have rather
significant criminal records, larceny, burglary, robbery; you name
it, all kinds of different things. Usually non violent, any violent
stuff they usually don't put them into Prop 36 but the non violent
drug users, a lot of them dealers, they've been caught dealing,
holding, whatever. And so, that initially represented the majority
of clientele, which, was a little different than what we anticipated.
Most of them to start with are level threes because they had more
of a history, so they were 10-month mandated treatment clients.
And now, its like nothing, we're getting more of what Prop 36 was
initially designed for and that is to get people who been caught for
the first time using or the third time and didn't have any
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concurrent legal problems and who basically were using or holding
or dealing for the first time. And some of these people are level one
four and a half months and eight months level two. -Los Angeles
County Program, Residential and Outpatient Provider
I think the women that we first saw, and it might have just been
who they were as people, knew more that almost that they were in
control. And I think now that the women that we have are more
like any of the other criminal justice referrals, that they still see the
court as having the power. Orange County Residential Program
The Prop 36 clients have had longer, more intense drug use, and
have other sets of problems, going back to when they were
children. They've been incarcerated more, Prop 36 people have
been incarcerated three, four, maybe six times during their lifetime
before they get to have Prop 36, so they have a more extensive
criminal history. And they have fewer resources, family members
who have just given up on them, that type of thing. Whereas the
regular population still have jobs, etc. and family that are still
supportive. Prop 36 people, because of their criminal history over
the years, have been sort of dropped by their people. Los Angeles
County Outpatient Program
Um, and so they have a little more going for them. We find that
they are not the hard core what we call gamma alcoholics, or the
hard-core drug heroin users, that are coming to us. They still have
a lot of their teeth, they still have a lot of their mentality, and they
don't have the wet brains that we see a lot of times, they still are
savable. Now whether they want to be saved or not is a whole
different story, but they seem to be a lot more savable. We get a lot
of young clients, a lot of young clients from Prop 36. We don't see
a lot of older senior citizens under Prop 36. Orange County
Program, Residential and Outpatient
You know, in the beginning it seemed like we got people who were
not interested in recovery at all. They reminded me of traffic
school clients, you know , I'm here because I have to be here, I don't
want what you people are selling, tell me what I have to do and I'll
do it. And that's not the clientele that we work with here. We only
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work with criminals who need recovery. We don't do treatment
programs for just your normal people who like, just had a bad day
at the office and their wife threw them out of the house and now
they need a treatment program. All our clients are criminals. —
Orange County Outpatient and Residential Program
However, for those programs that did not have prior experience
with criminal-justice-involved clients, though they were in the minority of
programs interviewed, this lack of experience was felt throughout the
program as they attempted to come to terms with working with the
Proposition 36 clients.
I started in the business of PC1000. ... Because this was our first
exposure to felons, well not to felons, there are a lot of felons on
PC1000 interestingly enough for other offenses but this was the first
time in working with a group that was sentenced to more than a
year in jail and released into treatment. So we didn't know much
about the population, and we got burned in the beginning. We just
didn't realize the criminality of the population, I might say, which
means more in the way of manipulation, more in the way of lies ...
-Orange County Outpatient Program
Several times, and it was just more criminal involvement than we
were used to and so, some of the clients we were getting were a
little harder around the edges. — Orange County Outpatient
Program
Um, some of them were, it was kind of like an element that we
didn't see before. Most of the people who have been through our
program were low level, first time low-level offenders. So we were
starting to get a different kind of a client who, some of our staff
wasn't used to seeing. Not so much the counselors but the office
staff that w ere supporting the program . O range C ounty
Outpatient Program
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The differences in experience appeared to be dependent on the type
of program. Residential providers had much more experience prior to
Proposition 36 with criminal justice involved clients. Outpatient
providers, even though they may have had some experience with criminal
justice involved clients, did not have quite the same types of experience,
or enough experience with a criminal justice involved, drug using
population and therefore, they had more to learn about working with this
type of population. Those outpatient providers who had the least amount
of experience with the types of criminal justice clients they received under
Proposition 36 were those who were mostly PC 1000 providers. PC 1000
(Penal Code 1000) is the drunk driving legislation that requires anyone
arrested while under the influence of alcohol for the first time to undergo
a certain number of educational hours with respect to the risks of driving
while under the influence. These providers tended to depend on an
education curriculum that was heavily dependent upon the convicted
driver submitting to a set number of "seat hours" during which they
watched videos and completed textual readings on the risks and
consequences of driving while under the influence. The curricula were
based on a classroom m odel. These clientele, especially the first-time
driving under the influence (DUI) clients, were mainly middle-class
individuals, sometimes young adults, who had no previous convictions
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for any misdemeanor or felony. This group was not the group that
programs received under Proposition 36, and programs with experience
with this group did not have experience, through PC 1000 clients, with
users of harder drugs and illegal drugs.
B. Findings—Hypothesis #2
Hypothesis #2: Programs with a clear organizational structure for
Proposition 36 clients and procedures will report a more positive
experience with implementation than those without such structure.
Information for this hypothesis was elicited by the question: "What
is the organizational structure of the administrative staff, the director, and
the counselors who work with the Prop 36 clients?" and "Have you hired
any new staff to assist with work on the Prop 36 contract?"
Most of the programs fell into one of two categories: either they
had a discernible structure with a chain of command that involved at least
two staff members, or they had a supervisor of some sort (clinical director,
Proposition 36 coordinator) who had primary responsibility for running
the Proposition 36 program, who may or may not have had any staff
reporting to them.
I have a coordinator for that program and she staffs it and makes
sure that the groups are staffed and she reports to me. And she has
a support person— there is a lot of paperw ork. -O range C ounty
Outpatient Program
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We have our division director ... we have our Project Director and
then we have our Clinical Director. And then we have our
counselors and the support staff. Our counselors, if they have any
issues regarding any of the clients or any concerns, they are relayed
to our clinical director, who, if at that point they can't answer any
of the questions they have, they would refer to the health care
agency. -Orange County Outpatient Program
I would say we all do. So everybody, we have three different
contracts and everybody works with everybody. We have, my staff
would be, 15. -Orange County Residential Provider
Well our structure for this particular program, we have our clinical
directors, who are all CSWs, and I'm the program administrator, so
I do more of the administrative types of things in terms of
paperwork and managing, I can also substitute groups, but I do
more of the managing of the personnel and the paperwork and the
reporting and that type of thing, I meet with the county
consortium, I'm the liaison, back and forth between the agency and
the county. And then we have facilitators that actually run the
group then, under that we have just our office clerks, our
administrative clerks that help run the program. Well, let's see, we
would have three half-time and one full-time that are program
directors, whether it would be clinically seeing them in the groups
or individually, and then we have probably two halftime clerks. -
Orange County Outpatient Provider
I'm the director and R— is pretty much is in charge of the prop 36
program. J— is our administrator and she does some of the
interaction and paperwork and stuff, but R— is really responsible
for the client files and she attends the meetings. We have another
counselor here, A—, she also participates in some of those, we have
a couple of other contracts, and so, I don't really have any use for
an administrative hierarchy. -Orange County Outpatient and
Residential Provider
W ell, we have our front line person, who is our front desk person.
She's also serves as a case manager. She's primarily more
responsible for scheduling, enrolling, making sure all of the
paperwork is okay. Then we have our crew of case managers and
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counselors who actually assist the clients and then we have Jackie,
who is our program director, who oversees the program, the day-
to-day operations. Then above Jackie there's me, the Executive
Director, and I attend all the meetings and make sure Prop 36 is
running smoothly. -Orange County Outpatient Provider
Okay, that's a good question. Cause its kind of scattered cause they
go off into, they're not just Prop 36 this group or Prop 36, its
intermingled with everybody else, so I carry ten residents, we've
got three different groups, so their group facilitator could be in
three different sections, so that would be really hard to say. Plus
different people do education classes that they're affiliated with. —
Orange County Residential Provider
Well, we have a clinical director, who's under me. We have
program director. The program director is in charge of all of the
administrative process, the clinical director is in charge of seeing
that the curriculum stuff that I fundamentally design for our group
is carried out and he's in charge of keeping everyone on the same
page, the groups and the different offices are teaching the same
course on the same night and kind of run it like a junior college. -
Orange County Outpatient Provider
The program has a total of 8 staff, and 6 of those work with Prop 36
clients. The reporting structure is, there's a Program Director, then
Counselor, then Program aides, and finally the House Manager. -
Los Angeles County Residential Provider
In our department, because that's all I can talk about, I'm not too
hip on the residential guys, but one, two, three, four of us. Our
outpatient department has five employees; there are five of us. The
director of outpatient services is our supervisor and we're all just
four caseworkers. I guess the reason that I got stuck with the
whole Prop 36 program was because I was the first one for the first
nine months of the program. It was just me. And I handled
everything Prop 36 but then we got, we went from having like 20
Prop 36 clients to 50 Prop 36 clients and I couldn't handle it so n ow
we sort of spread it around. -Los Angeles County Outpatient and
Residential Provider
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Well, F— is the Executive Director but basically he doesn't, I guess
he does the billing. And V— is the clinical director so she oversees
all of us who work here, but I'm actually the case manager, I'm
really in charge all of that, so I do all of the, I don't see all of the
clients. But in the beginning I did until it got too big and now
others do, but I do all of the progress reports and we just recently
hired someone just to do the urine testing stuff because I couldn't
take care of all of it anymore. So that's pretty much the pyramid,
he's the Executive Director. Then we have a clinical director but
she just kind of more or less monitors the charts. And I oversee all
of the paperwork and progress reports and G— does all of the
urine testing stuff, which gets reported to me, which goes to the
court. And then we have our interns, who do individual therapy
and run groups and stuff like that. -Los Angeles County
Outpatient Provider
We've two counselors, technically three counselors because I also
function as an outpatient counselor so we've three counselors.
We've got myself as the MIS person, I do the intake on the
computer, I do the treatment planning and all of that and the
progress reports via the computer, so I take care of that. The
contract coordinator does the billing for Prop 36 and also I do part
of the billing for Prop 36. My administrative assistant works again,
in an administrative position and also when they go to sober living,
she is the sober living coordinator. So there's an entanglement but
its very clear to us. -Los Angeles County Residential Provider
Most of the programs interviewed fell into two categories: those
that employed more than 20 individuals and those that employed less
than 20. Those that had more than 20 employees had more or less formal
reporting structures, which included an individual with primary
responsibility for Proposition 36, w h o w as either a counselor, a case
manager, or a member of the administrative staff. These individuals
tended to report that the majority of their time was spent on
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Proposition 36-related activities, and these activities usually involved
some direct client contact. Those programs that employed fewer than 20
staff were more likely to have one person with responsibility for
Proposition 36 activities, but that individual spent time not only on
Proposition 36, but also on a variety of other contracts or programs,
including some time spent in direct service activities with clients.
Programs with fewer than 20 staff were more likely to have all staff
working, at least a portion of their time, on all of the contracts or
programs they administered, including Proposition 36. In these
programs, staff tended to "wear many hats." It should also be noted that
in many cases, the respondent did not know how many staff were
employed by the program, but generally could count up the number of
staff working on the Proposition 36 program. The table below shows the
number of employees at each program, the number of those employees
who were directly involved in Proposition 36 activities, whether the
program hired new staff or not to work directly with the Proposition 36
contract, and the type of job position(s) that were hired to work on
Proposition 36. With few exceptions, the majority of programs that hired
n ew staff hired counselors.
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Table 6. Number and Type of New Hires by Program
Program County Total Staff Prop 36 New Type of new
staff Hires? Hire
#1 Los Angeles 50 5 Yes Case Mgr
#2 Orange 47 4 Yes Counselors
#3 Orange 20 6 Yes Counselors
#4 Orange 18 6 Yes Counselors
#5 Orange - - No -
#6 Orange 15 15 Yes Counselors
#7 Orange - 3.5 Yes -
#8 Orange - 4 Yes Case Mgr
#9 Orange 17 17 Yes Counselors
#10 Orange 40 - Yes Counselors
#11 Orange - - No -
#12 Orange 10 10 No -
#13 Orange 15-17 4-5 Yes Intake
Interviewer
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Table 6. Number and Type of New Hires by Program (continued)
Program County Total Staff Prop 36 New Type of new
Staff Hires? Hire
#14 Orange - - Yes Counselors
& Admin
#15 Los Angeles 63 53 Yes Counselors
#16 Los Angeles - 3 Yes Counselors
Intake
#17 Los Angeles - - No -
#18 Los Angeles 8 6 No -
#19 Los Angeles 20 2 No -
#20 Los Angeles 20 20 No -
#21 Los Angeles 5 1 No -
#22 Los Angeles 9 6 Yes Counseling,
Intake,
A dm in
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Table 6. Number and Type of New Hires by Program (continued)
Program County Total Staff Prop 36 New Type of new
Staff Hires? Hire
#23 Los Angeles - - Yes Counselors
#24 Los Angeles - - Yes Counselors
#25 Los Angeles 15 5 No -
#26 Los Angeles 23 6 Yes Counselors,
Intake,
Admin
#27 Los Angeles 9 9 No -
#28 Los Angeles 22 10 Yes Admin
#29 Orange 15 15 No -
#30 Los Angeles - 5 Yes Counselors
#31 Los Angeles - 5 No -
#32 Los Angeles 100 15 No -
#33 Los Angeles 15 3 No
-
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Table 6. Number and Type of New Hires by Program (continued)
Program County Total Staff Prop 36
Staff
New
Hires?
Type of New
Hire
#34 Los Angeles - 4 No -
#35 Los Angeles 8 8 Yes Counselors
#36 Los Angeles - - Yes Urine tester
#37 Los Angeles 5 5 Yes Routine
vacancy
#38 Los Angeles 15 6 No -
#39 Los Angeles 45 15 Yes Counselors
#40 Los Angeles 8 2 Yes Counselors
#41 Orange 22 10 Yes Admin
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Little support was found for the hypothesis that administrative structure
had an impact on Proposition 36 implementation. Programs tended to
report that they either had an administrative structure that involved a
traditional hierarchical pyramid reporting structure, or they reported that
all staff did many jobs, with an Executive Director or other individual
providing oversight and direction to all staff positions within the
organization. Many programs reported hiring new staff, but they did not
report lack of staff or the time and effort to recruit new staff as either a
burden or otherwise affecting program performance.
Not specifically, but we broadened the staff because we had more
clients, but we don't technically dedicate our staff to Prop 36,
they're just another treatment modality cause we do non Prop 36
outpatient, non Prop 36 residential. We have general relief, which
we refer like DPSS to maintain their general relief benefits they
have to stay in treatment, so we disperse the caseload based on
who has the least number of clients at a particular point in time. -
Los Angeles County Outpatient and Residential Provider
Several programs indicated that the most important individual
within the Proposition 36 program was the judge (or judges) involved
with the Proposition 36 clients through the courts. Program staff was
never named, either as individuals or as positions, as being the most
im portant person to the Proposition 36 program . They indicated a
broader definition of the Proposition 36 hierarchy that included all of the
Proposition 36 representatives, not just within their treatment program.
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Some of the judges are there whom we work with. It's a court
m andated program and its one that really relies very heavily on the
judgment of the judge. The judge really has the ultimate say in
what transpires with any given client in the program. And in some
cases that's good and in some cases it does create problems for us
because some judges release people from aftercare or continuing
care which we don't think is a good idea, and they do some things
sometimes that make it a little difficult for us, but I think that
relationship between providers and judges has improved
considerably as this program has evolved but its been a program
that started with certain rules, regulations, standards, what have
you and some of that has changed as it evolved. -Los Angeles
County Outpatient and Residential Provider
We have two fulltime [staff] who work Prop 36 and I'm part-time,
P— is part-time and W— is part-time. P— also is our
administrator. He does all the court reporting. See Prop 36 is not a
physician-based program like Medi-Cal, it's a court m andated
program, so your key individual is the judge and the commissioner
... -Los Angeles County Outpatient and Residential Provider
The other thing is that you can have all the meetings in the world in
all the SPAs in the world and if there isn't a judge sitting there for
that SPA who actually runs and makes the final determination as to
what gets done with the participant, you can make all the great
ideas in the world, but unless the judges get on board with it, it
doesn't make sense to have these meetings and tell people you
going to be able to affect a whole bunch of change by attending the
meetings because it's the judges that run this thing. -Los Angeles
County Residential and Outpatient Provider
C. Findings— Hypothesis #3
Hypothesis #3: Frequency and intensity of the participation in
training provided by the counties will affect the programs' experience in
im plem enting Proposition 36.
The questions regarding the role training played in drug treatment
providers' experience of Proposition 36 were phrased as: "What role
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did the county play in providing information concerning the
implementation of Prop 36?" and "What role did the Central Assessment
Centers play in providing information concerning implementation?" The
second question was only asked of respondents employed in programs
located in Los Angeles County, as Orange County did not implement
assessment centers, but the county did all of the assessments itself at one
centralized location.
For the most part, most programs were enthusiastic about the
training and attended sessions for the information they provided on
accessing the shared data system each county developed for tracking
clients across the treatment programs, the courts, and probation. Both
Los Angeles and Orange counties developed a shared data system that
was based on using the Internet to gather data from each of the
participating programs. The data system for Los Angeles County was
especially impressive, as the developer of the program won a national
award for its design and implementation. The program employed a
complex security system. Each person trained on the system received a
card (about the size of a credit card) with a computer chip inside. The
card w as part of the security system , and, at any given m inute of the day,
it provided an authorization code for accessing the system. This access
code changed continually, so only those individuals who had a card
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and training on its use were able to access client records within the
system.
Yes! The card. I have mine in my desk. The training was very
excellent and they gave us a bunch of material to reference when
we had questions and stuff. It was frustrating for us to learn it
there and come back here and it didn't work quite that way. But
the support, the phone support, the help desk was very very
helpful, so they sat there with me one day and walked me through
step by step while they were working on the computer at their end
and fixing it so I could access it and whatever. So, it was really
very helpful. All along, they helped us, no resistance whatsoever,
no lag. We got what we needed. -Los Angeles County Residential
Program
The county provided training. The county provided a couple of
you know, half-day seminars on how to use the system. I attended
one and just came back and began slowly training our staff here.
We don't have too many staff that are using it. -Los Angeles
County Residential Program
... We were trained on all of that and Prop 36 has a separate
training. And, I spend a lot of time in training. Its good training,
its excellent training. After you get that training you can go
anywhere and work Prop 36, you know, it teaches you how to edit
clients' data on the TCPX system. That's what it is. When they
come into treatment, CASC will call us and ask us do we have any
beds, and we will say yes. And they'll tell us who they have, you
know. -Los Angeles County Residential Program
I got most of my training from my counterpart in residential. He
kind of showed me around the computer system but when we
expanded in our department, we had to go down to somewhere
out that way, to go to some training to get the cards, the access
cards. And in order to get an access card, you have to sit through
this training so three of us w en t d o w n there and sat through a six
hour training on the TCPX system, and other than that, we get
every once in awhile we get a little pieces of paper from the ADPA
whatever outlining new definitions or new structures, like when
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the whole aftercare continuing care thing came up, little updates
kind of things, but other than that, Lab Corp, the people who got
the drug testing um, contract came out and did a training. That's as
far as it goes. -Los Angeles County Outpatient Provider
They had the training sessions for every little aspect of it. I was
given a manual for the TCPX. It required a basic computer literacy,
which I have. I went down to ADPA, and it was 8-hour session
where they explained the ins and outs of how to maneuver within
the system. And then we were issued our secure ID cards and it's
just like working with word or excel. It's that simple. It's just a big
database, so there's no problem working it. Anybody with any
basic computer literacy learns it pretty quick. -Los Angeles County
Residential Provider
This is something, it was a full day training for this and its
constantly I think as you go to the SPA meetings too, if there's any
modifications, if you go to the SPA meetings, um, or the CASC
meetings, there may be always updates. Even yesterday we heard
a little bit of an update at the Lab Corp conference. There was
some new information, so a lot of this the modifications or updates
are given to us at SPA meetings, CASC meetings, because there are
every now and then these little glitches in the system here and
there. So, it's been a brand new program, so that a lot of it has
been, where it's been a lot of a type of trial and error type of thing
too. -Los Angeles County Outpatient Provider
Initially, what I can remember, the county had sent notices that
Prop 36 was going to be implemented, and there was going to be
trainings. It was very unclear as far how often these clients needed
to be seen, um, how we were going to get these clients, the
referring of the clients. Um, it was slow. We had maybe one or
two clients in the beginning. And the progress report, the whole
process was difficult because the TCPX system w asn't set up right
away so we had to fax them reports, so it was pretty slow in the
beginning. I would say it was difficult, to be honest with you. -Los
A ngeles C ounty O utpatient Provider
Oh, yeah, there was training involved with regards to the actual
administrative piece and using their program and stuff. There was
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training involved in drug testing, in using the equipment that they
provided for us. There was training involved in using the
Addiction Severity Index which is something that they require at
the beginning and the end of treatment, so people had to learn how
to do that, although we had already been using it for other reasons
for the program, so there has been a learning curve associated with
that. Also there's the person, people who work with Prop 36 work
much closer with people at the health care agency and PO's.
There's a lot more ongoing feedback. Normally there isn't that
level of feedback required but with Prop 36 there is, so they are
busy communicating with the people who are responsible for their
clients a lot. - Orange County Residential Provider
The following provider, an outpatient program, had no computers
prior to implementation of Proposition 36. Proposition 36 made it
necessary for the program to obtain and use computers in a way it had not
before. Initially, they had only limited access to computers, which put
some strain on program activities.
I had two days; well it was training on two different areas of the
system. And the staff all had one day. And that was on just one
area of the system. You know, prior to Prop 36 the clinical staff had
no computers whatsoever. We had no computers. So, with Prop
36, we had to go to computers. Then we went to one computer and
we had to go upstairs [to use it]. -Los Angeles County Outpatient
Program
The following program did not consider the training to be of
benefit to it because, as an outpatient program, it is paid on a fee-for-
service basis. As such, fee-for-service does not reimburse programs for
time spent in training and meetings. All the training and meetings were
considered to be a burden for the program, and they were watching the
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time spent in those activities very closely to see if the financial impact on
the program was enough to justify attending.
And we've had a county contract for that since like 1984 and that
works great and its units of service and they pay for staff however
we staff it, and this was just totally different. So there's no money
to cover attending county meetings, training your staff, all the
paperwork, and so it was a losing situation for us. And I'm still
sure that we're just barely, we're watching it real closely now that
people are trained and everything, but it's costing us, it's marginal,
it's close. -Orange County Outpatient Provider
D. Findings—Hypothesis #4
Hypothesis #4: The extent to which Proposition 36 (treatment
versus incarceration) reflects values already held by the
organization will affect implementation of Proposition 36.
The question regarding the extent to which Proposition 36 reflected
values held by the treatment program was posed as: Were there strong
advocates either for or against Prop 36 as legislation within this treatment
program? This question was based on the presumption that not all
treatment providers supported a treatment approach to drug use in the
form that it was implemented in Proposition 36. The theory holds that the
drug treatment providers would have some response to the values
imbedded in Proposition 36 beyond simply reacting to the fact of a larger
pot of funding becoming available to treatment providers as a result of the
legislation. Support for this hypothesis was found in the interviews with
providers.
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There were a couple of levels on which programs reacted to
Proposition 36 implementation based on their program values or values
held personally by treatment program staff. One common theme
articulated by several programs was the lack of understanding of the
criminal justice players, the judges, the probation officers, about drug
treatment and concern that the criminal justice aspects would not
approach drug treatment from the correct perspective.
Yeah, when they first announced i t,... the CEO, she thought it was
a good idea, but she also thought, and she voiced her concerns, at
one of the first central committee meetings that they really, the
probation officers and the judges needed to get a lot of input from
providers. In her experience in dealing with courts and criminal
justice system ... they didn't know what treatment was. You only
have maybe two or three drug court judges who had a lot of
experience dealing with treatment, who know exactly what
treatment is, how to design it, what you are checking for, what you
need, and she tried to make sure that in the initial phases, that
providers were not just asked to comment but that would be the
basis for formulating the plan for the treatment aspect, then up to
the criminal justice system down, that's a bad interface for
treatment. -Los Angeles County Outpatient Provider
We have to do a lot. ... And the problem that we also have is the
court system because there are individuals out there in the court
system, judges and the like, parole officers, who believe that it is
okay to drink. And we're a zero tolerance program. And that
makes it more difficult for the clients. So, we have to educate them
[the judges and parole officers] in that fashion. That it is zero
tolerance, that alcohol, ethal-alcohol is a drug also. Los Angeles
C ounty O utpatient Program
Providers also voiced concerns regarding the values embodied in
Proposition 36 that the treatment standards were not rigorous enough.
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Some providers, for example, especially residential treatment providers,
felt that three months of residential treatment, as mandated under
Proposition 36, was not sufficient and that, from their point of view, at
least a year of residential treatment was necessary to ensure success of the
experience.
We actually were opposed to Prop 36. The official view of [our
program] was that we were opposed, primarily because we believe
that it was undercutting some of the tools that we use to encourage
people to stay in treatment. So we have good relationships with
drug court and the judges around the county, and being able to get
people's attention by threatening to incarcerate them or
consequences for noncompliance or failure to complete treatment
was a viable tool for a lot of people. We believed that once Prop 36
passed, that people would not be motivated to stay in treatment.
Orange County Residential Program
Many programs supported some practices of Proposition 36, but
not other practices. For example, the provider below was very supportive
of the levels of treatment mandating longer stays in treatment, but the
interviewee was philosophically opposed to lower levels of assessment
with shorter treatment stays as being inadequate.
I would say advocates for with the six-month and above programs,
the six-month and yearlong programs. We do not accept the 30-
day or the 90-day clients here because our programs not set up for
that. ... What happened, in the beginning, the other person who
was coordinating the program allowed the 30 day and the 90 day
p eop le in to the program , so for the first six, nine m onths or so w e
had some 30 day and some 90 day people. The problem was that
our program is not set up, so we don't believe that at 90-days
someone's ready to go out and look for work. We don't believe
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that at 30 days, they are ready for an overnight pass and that's
what the other programs do, they'll do 30 days in. And we think
that is a set up. We think that is like an atrocity to set people up
like that. ... A set up to fail, it's unrealistic; it's just not a good
idea. So we were taking some of the people but they were all
leaving at their 30 days or 90 days and in our opinion, they weren't
ready. They weren't ready in our opinion to go look for work yet
because our program is not set up for them to do that till about five,
six months into the program. So we said we are not taking any
more 30 day or 90 day people and have had to make that very very
clear. To the county, to my monitor, to the program, the
importance and integrity of our program and the necessity of
keeping it so that six-month people we will take because we do
have a component where they can do six months in and then a year
out, actually its an 18-month program. But we do have it set up so
they can do that, so we do take the six-month people. What
happens is that six-month people stay a 12-months, once they get
here six months, they really really likely to stay farther in the
program. -Orange County Residential Provider
Some providers also felt that the lower levels of recommended
treatment under Proposition 36 were not sufficient to accomplish the job
of assisting the addicted individual in making a recovery. The higher
levels of treatment, especially those involving residential treatment,
would be his choice for all Proposition 36 clients.
Yeah, I think the main thing is about the lev el... I think that we are
looking at Level One just for those clients who are employed or
have children or this and that, and I think a bigger one than this is
not enough residential slots for the clients. If it were really up to
me or up to my staff, every single one of them would be put into
residential. And every time I try to find space for them, we need
m ore slots for residential. — Los A ngeles C ounty R esidential
Provider
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The concept of clients w anting to be in recovery is very basic to
drug treatment providers' values. Many providers reported problems
with Proposition 36 clients, or perceptions of the Proposition 36 clients on
the part of other treatment staff or other residents, that these clients did
not want recovery, and therefore did not have the same commitment to
their recovery process as other clients.
They were stigmatized at the resident level oddly enough. They were
ostracized by the, I don't want to call them normal residents, but the
residents that came by way of making a decision and a choice to get
through recovery, not having the court make it for them. So, we found
in the first year, they had a tendency to get blamed for a lot of the
things that were going wrong in our program, and they became kind
of a scapegoat for participants. We had some staff that wanted to buy
into that but at our administrative level, like I said, we didn't see it that
way. I think we stayed the course and everybody else has kind of let
go of that whole scapegoating the Prop 36 people. Los Angeles
County Residential Provider
Other providers made a more subtle distinction between
Proposition 36 clients and the other clients who were not remanded into
treatment. Rather than seeing it as a conscious effort on the part of the
Proposition 36 clients not to "want" to be in recovery, the provider quoted
below saw it as an evolving self-perception on the part of the Proposition
36 clients to come to the realization that they had a drug problem and
need ed to do som ething about it. This provider felt that the problem w as
that some Proposition 36 clients had a problem self-identifying with
treatment and recovery.
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... They didn't choose treatment, it was chosen for them. Although
they wanted to cooperate for their legal reasons, um, those who
were still under the [jurisdiction of the courts], they were just
casual users or sellers, who took this option to not go to jail, [they
were] very resistant to treatment because, um they have a problem
identifying with it. And again, these are not responsible people,
that's indicated by their criminal behavior, but, so, you have them,
they can't even say, just for the criminal justice issue they need to
do this, they aren't that responsible, they don't relate to treatment
well, because in some its denial, some of it they are just actual drug
users, but they just got caught in an umbrella and they were there
to take the plea. Now you're finding more people have, you know,
they recognize that they have a drug abuse problem, they might
not quite be in the mode to say "I'm an addict" but they
understand it was in their lifestyle and these were the results. I
think I should moderate my lifestyle, this could help me, and
treatment could help me. So, you get more of that now. Los
Angeles County Outpatient Provider
The following provider indicates that, as a provider, he does not
know exactly what the process of recovery is, but that, at some point in an
addiction career, individuals make a choice to stop using drugs. The
process of creating an addict is "complex" and the process of unmaking an
addict is just as complex, and probably less well understood than the
process of making the addict. However, he echoes the other providers in
his assertion that an individual makes a choice between addiction and
recovery, and that the choice is pivotal if treatment is to be successful.
But, I think it's unrealistic to expect people, especially in the first
entry space of a low-level treatment to get it because the problems
that really go into creating a substance abuser are really very
complex and there's an interaction with lots and lots of factors
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unrealistic. But when people are ready, they're tired of using, they
will get sobriety and it's really their decision. I wish I could figure
out what it is that would make everybody stop and we're all in this
business of trying to do that for years, but clearly there's not an
answer. There's a process that people can participate in and
somewhere in that process they will either die or they get sobriety.
Orange County Residential Treatment Provider
But the majority of providers saw Proposition 36 as an opportunity,
both for drug treatment in general and for their programs specifically, and
they were greatly in favor of it.
Well we all knew we wanted to do it. We knew that the funding
stream would change dramatically under Prop 36 so all of us
within our agency were pro Prop 36. We wanted it and we wanted
to do it right. — Orange County Outpatient Provider
The most controversial aspect of Proposition 36, from the point of
view of the treatment programs and the values it placed on urine testing
and clients remaining "clean" while in treatment came out during
discussions of the lack of funding for urine testing during approximately
the first year of Proposition 36.
Yeah, it was crazy! You know, we thought it was crazy. We
basically, disbelief, it was disbelief because we couldn't understand
who in the world would create a program that mandated
outpatient and residential counseling without drug testing. But we
understood the county's position, if they have no money, no
funding stream, if it wasn't written into the bill, then how were
they supposed to pay for it? So, we didn't do drug testing unless
w e had to and w h en w e had to, w e absorbed the cost. Orange
County Outpatient Program
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Frustration, a lot of frustration. I think that spread across all of the
treatment facilities. We had provider meetings and the frustration
was just as well on the county end of it too. And it was quite
puzzling why that wasn't included in the funding or it w asn't even
written into the Prop 36 And part of it, it's a treatment tool to
know whether these individuals are clean or not. We've been put
in the position of having to buy the testing and absorb the costs.
Orange County Residential Program
Especially within the context of residential drug treatment
programs, urine testing is seen as a treatment tool, a therapeutic tool that
provides an objective measure of how well the client is doing in treatment.
If the urine test comes back positive "dirty", treatment counselors know
that there is cause for concern that the client is not making progress in his
or her treatment plan. But urine testing is also seen as an obligation on
the part of the residential program to ensure that none of the residents of
the treatment community is using. In this way, they can fulfill their
obligation to other clients to offer and provide a "safe" place for them to
focus on the recovery process without the temptations that one finds in
the outside world in the form of drugs. Many more of the residential
programs in both Los Angeles and Orange counties provided urine testing
out of their other program funds during the time there was no county or
state funding than did the outpatient programs. Because, in residential
programs, if one person brings drugs into the recovery community, the
consequences, not only for that client, but also for all the other
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residents, can be dire. The residential program faces a much greater
burden and expectation of providing a "safe" environment for drug
abusers in recovery, and takes more responsibility for that, than do the
outpatient providers. This makes sense as the residential providers have
much more control over a residential facility than an outpatient program
has over the living situations of its clients.
I guess since July, the county pays for it. But there's no way we
were going to let clients be dirty, we don't want clients coming in
loaded, and other clients seeing that and saying, what is that? How
come they're loaded ... --Los Angeles County Residential Program
It's not fair for the ones who are really trying, and this one's
coming in under the influence, it's not fair for them, and it's like we
have to give them, let them know that this is a safe place for them.
And then they're like, we're not going to reimburse you and that's
okay. We'll take the loss because we're not willing to risk ... we
have signs posted on our walls that says you can't be under the
influence or have used within the last 24 hours. --Orange County
Residential Program
Their reactions? Well, they were shocked, you know in the
beginning for the first probably six months we weren't able to do
that and we knew other programs had been running for a while,
and just ethically, we were so concerned to be able to serve this
population that is one of your tools, a very important tool to use
and you know, we tossed around also ethically, is it practical for us
to provide the money up front. And write it off as a loss, but the
reality is that isn't practical either. Nor do I think it really sets such
a good example for what we try to teach our clients, that we're
going to give you all kinds of things, you know, that goes to my
o w n conservative line of thinking, I don't believe in harm
reduction, I believe in recovery, and so, I don't believe in just
reducing the problems, I believe in giving them an opportunity and
having an expectation that they can recover and be productive and
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such, and if we're bending all the rules for them, I don't think we
are setting the right kind of example. Orange County Outpatient
Program
Well, that was addressed recently by the passage of legislation that
allowed them to buy testing and give it to us. Before that, for us it
was a big issue, people in substance abuse treatment in general
believe that drug testing is an important motivational factor for
people in recovery and so, we do drug testing and we do it
randomly, and even though we w eren't getting paid for it, we still
were drug testing people because we thought it was necessary. But
now with the funding, there's a lot of drug testing going on and we
think that's better. The county gave us a breathalyzer, which is
kind of an expensive piece of equipment for alcohol testing and
they provide the drug tests, the urine tests for us and there's a
requirement that the residents are tested, so those people are
getting pretty concentrated treatment with regards to the testing.
Orange County Residential Program
E. Findings—Hypothesis #5
Hypothesis #5: The extent to which the treatment components and
modalities espoused by Proposition 36 are already incorporated into the
drug treatment program (12-step orientation, group therapy orientation)
will affect the experience of Proposition 36.
The technical core of most drug treatment programs is counseling,
either individual or group sessions. The extent to which Proposition 36
incorporated aspects of drug treatment that were already in place
provides insight into how it would be accepted by drug treatment
providers. Alternatively, the extent to which Proposition 36 required
drug treatm ent program s to im plem ent som ething w ith w hich they w ere
unfamiliar would also affect the programs' experience with Proposition 36
implementation. To test hypothesis #5, that is, the effect of Proposition
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36 with respect to existing treatment modalities, several questions were
asked. One question was: "What were some of the characteristics of Prop
36 implementation at your treatment program?" Another was: "What
decisions had to be made initially?" Another question was: "What types
of treatment modalities does your program currently provide?" And
finally: "Does Prop 36 fit in with these existing treatment modalities?"
Many of the providers felt that one of Proposition 36's strengths
was that it built on many of the preexisting structures already in place for
persons wishing to recover from drug abuse.
The CASCs determine their level of treatment based on the ASI and
our treatment program meets or exceeds the standard of the ASI.
We're based on the social model, which means that we advocate
the 12-step recovery process. --Los Angeles County Residential
Provider
No, I think it's a very positive effort by the judicial system and by
society in general to provide treatment to this population, to the
recovering population and its using some pre-existing structures
out there such as 12-step, so its actually been a very good idea.
There's, I think it was a very positive, a very positive route for
society in general and the justice system in general to go into and to
move into. But I think this is really the beginning of what we may
see other types of programs nationwide are being implemented,
either hopefully passed by the voters. I think really, a lot of people
are really looking to California to see if this is going to be
something happening, you'll see that in your dissertation where
this is not something that's being utilized throughout the country.
Its alm ost like we're like a test case in som e sense. — Los A ngeles
Outpatient and Residential Provider
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There are programmatic guidelines that say they must attend three
sessions here, each two hourly a week. They understand that they
would be individual counseling, there would be group therapy
sessions, there would be urine testing and this is done weekly.
And then part of our counseling includes training in anger
management, behavioral patterns, staying sober, and then they also
have to, we monitor, we don't provide them with 12-step meetings,
but we monitor their attendance at such. So they have to go. So we
balance what they get there with what we do here at the individual
one-on-one sessions. And then we have with that, some might be
homeless, some might be looking for work, some may be trying to
find the cause of trying to stay away from drugs and start up
everything. It becomes our responsibility to talk to them, to refer
them to other agencies, to help them with looking for work when
we can, send them to the various government agencies that provide
resources, help and facilities. -Los Angeles County Outpatient
Provider
They have particular independent living skill issues and needs that
really don't come up in the long-term clients until they've been
here about seven or eight months. Although they participate in
many of the same therapeutic activities that we have for everybody
else they need some specific extra additional help with regard to
that stuff. And there's more of a focus on hooking them up with
12-step programs too which is something that we have only
recently in the last few years embraced having our people be
involved in 12-step programs. Lots of programs rely on 12-step as
a therapeutic framework, but because we are a therapeutic
community we have something else although very similar in many
ways to 12-step work. — Orange County Residential Provider
In addition to the structures already in place, such as 12-step
meetings, Proposition 36 introduced some care strategies that were not
universally implemented in drug treatment programs prior to
implementation of Proposition 36. One such strategy was aftercare, which
involved clients in continuing access to treatment in the form of groups
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and follow-up with counselors once their actual treatment stay was
concluded.
Aftercare is leverage and more than telephone follow-up. In
aftercare, the mixing of clients still in treatment and in aftercare is
good because then there is some peer experience in the group. The
clients in treatment can have the experience of seeing women who
have successfully completed the program, who serve as role
models of successful women. - Los Angeles County Residential
Provider
It was very clearly spelled out in the RFP and the contract that
there'd be no payment for aftercare. We were not utilizing our
funds, we were behind and we were allowed to charge once a
month for aftercare, but that's long gone now. Another thing that's
spelled out is that w e'd have aftercare clients who had not been our
clients in treatment to be sent to us for aftercare. That was not
anticipated but the way our aftercare runs unlike I know of a lot of
agencies, we chose not to have a separate aftercare group. The
reason for that is that we found that the clients who are in aftercare
are all clients who have completed the treatment phase of the
program and they are a very positive influence on the clients in
group that are still in the program. So we integrate our aftercare
clients into our regular groups and it's a big help. Very positive. -
Los Angeles County Outpatient Provider
Some programs expressed concern about the fragmentation they
perceived in the treatment clients were receiving under Proposition 36.
She [a client] gets credit for that past time in another treatment
center and so what they're doing is 6,3,6 and that means that they
do residential, that's 6 months, which is 180 days. We can no
longer keep them over 180 days because Prop 36 says we're not
going to pay you for them. You can keep them, but we're not
goin g to pay you for them . Then, after the six m onths, they go to
court and we give them a progress report before they, say like the
lady is being discharged from here and she has to go to court next
Monday, I would give her a progress report because I'm still
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responsible for that progress report. She goes to court and what
the judge will do is, um, find an outpatient treatment [program] to
send her to, so she's done six months residential, the next phase is
three months outpatient. And then after that, she completes the
outpatient program wherever she is, she would have to do, she
goes back to court again from the outpatient, and then the judge
would select a place for her to do six months continuous aftercare.
Now all the while that she's in this, residential, you get the one-on-
one counseling, you get your groups, um you get all of that stuff.
When she goes outpatient, the same thing, she gets the groups, the
UA testing, all of that. Then in continuous aftercare, the same
thing. They just up the groups sometimes to two or three 12-step
meetings a week, however that program sees fit to do the criteria.
So that's changed because what used to happen was that, when
they did the time in the treatment program, outpatient, whatever,
they were cut loose, but because of so many relapse episodes, they
decided to put something there to reinforce that client. To keep
that client in treatment, give that client some more. So, its 6
(months), 3 (months), 6 (months). Six months of the residential or
outpatient. If its outpatient already that they're in, of course, then
it w ouldn't fit, I'm speaking for residential. So, 6,3,6, so that's
w hat's changed that I can say right now. I think it's been really fine
tuned, whereas at first, we were really having some problems.
Nothing was like structured and they were like testing, "we're just
testing this out and it's going to work out" and it has finally. -Los
Angeles County Residential Provider
So that's a pretty good ratio and th at's the reason we took over
outpatient and aftercare. We wanted that additional component
because we were only given 90 days residential. And then they
would have to go back to Healthcare and be reassessed, and go into
an outpatient or aftercare program. They would get a whole new
counselor, they would go to a whole new building and we wanted
them to be more comfortable. If we can give them 9 months to a
year, I mean that's a continuum of care and a great foundation for
them to start out on. 90 days gives them basically, you know what
I m ean? A nd then they have to be jolted and get a n ew counselor
and they don't feel comfortable. So the best thing for them is to
stay with the continuum of care, if possible. We do fully encourage
them to get back to their families and children, whether it is
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Fullerton, Garden Grove or wherever they've come from but we
also want them to have a good foundation to go back with. So,
sometimes we have a girl who completes her 90 days here and then
wants to go home. So of course they're going to get an outpatient
in Fullerton or in Garden Grove. Our outpatient is here in Costa
Mesa but our continuum of care is right here now and we have it
and its going to be working out a lot better because then we can
hold them for a longer period of time, track them for a longer
period of time. You know, tracking on these young ladies is just
unbelievable because they have so many aliases and they're so used
to hiding and running, that once they're gone, they're gone. You
know, its like, you want to do follow-up, yeah, we cannot find
them. You know these hotels up and down, and different
addresses and it's amazing. — Orange County Residential Provider
F. Findings— Hvpothesis #6
Hypothesis #6: Staff perceptions of the clients coming into the
program under Proposition 36 (compliant, difficult, more or fewer needs
than other clients) will affect the programs' experience with Proposition
36 implementation.
The programs' perceptions of the clients coming into the program
under Proposition 36 were crucial to the success or failure of the
implementation of the program.
Hypothesis #6: Staff perceptions of the clients coming into the program
under Proposition 36 (compliant, difficult, more or less needs than other
clients) will affect the program 's experience with Proposition 36
implementation.
... They w ere under pressure. Therefore, they didn't choose
treatment, it was chosen for them. Although they wanted to
cooperate for their legal reasons, um, those who were still under
the, they were just casual users or sellers, who took this option to
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not go to jail, very resistant to treatment because they have a
problem identifying with it. And again, these are not responsible
people, that's indicated by their criminal behavior, but, so, you
have them, they can't even say, just for the criminal justice issue
they need to do it this way, they aren't that responsible, they don't
relate to treatment well, because in some its denial, some of it they
are just actual drug users, but they just got caught in an umbrella
and they were there to take the plea. Now you're finding more
people have, you know, they recognize that they have a drug abuse
problem, they might not quite be in the mode to say "I'm an
addict" but they understand it was in their lifestyle and these were
the results. I think I should moderate my lifestyle, this could help
me, and treatment could help me. So, you get more of that now. -
Los Angeles County Outpatient Program
The initial impressions of the clients affected perceptions of how
the whole experience with Proposition 36 was going to go.
I had a real hard time in getting my bosses to accept it. Basically
because they were going well we got drug court, drug court's
working good, and the first batch of people, the first few people I
got the first two stayed two days and got caught using in the room.
It didn't leave a good impression. It left the fact that now all's
we're doing is babysitting for the courts because we're getting
people who don't want recovery. And that was for the first few
months. Orange County Residential Program
Let's see, I got subpoenaed to Chino once because the guy was
upset, he didn't like the way we ran the place. Basically when they
first started coming in, it was just people not wanting to be here but
'I'd rather do 90 days in a program than 16 months in prison' is
basically what it broke down to. Staff was against it because we're
looking at, well, now I got someone taking up a bed and they aren't
serious about it. We got people out there who are dying on the
streets. And so basically, this is an indigent recovery program. We
cater to the street drunks, the street drug addicts, the w in os, and
now I got the law saying I got to do this so let me get this bed. So
there were some objections to it. Orange County Residential
Program
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Well the first, we got off to a great start. The very first three we
had were highly psychotic. So, I mean, that initial problem that has
become such a big deal today was evident for us from the very
beginning. I mean I have a newspaper clipping up there of my
very first Prop 36 client. Um, while in our program she stole a car,
got in a high-speed cop chase, got cornered on the street, and ran
over some cops and that was my first client. But after those first
three, it kind of settled down and it's really funny watching the
widespread the diverse group of people that are coming here under
Prop 36. There's some very minor affected people who just drugs
crossed their path, wrong place wrong time, really not drug addicts
that are coming here and they are fairly easy to deal with you
know, they come in short term, they're very willing very motivated
to just get through their court case. You know, to this forty-year
long heroin addict who can't stay clean for five minutes in an
outpatient program, so it's really a diverse group of people. I don't
know, the court giving them the added motivation, you know,
you're going to go to prison for three years if you don't complete
this, its really a good tool for the treatment program. -Los Angeles
County Outpatient Provider
G. Other Findings from the Qualitative Interviews
L The Addiction Severity Index
Many providers expressed mistrust of how the ASI was being
administered by the CASCs (or county assessment center for those
counties that are not as large as LA County and not divided into CASC
areas). For example:
Even in an hour, you don't get enough. And some of them they
take out an hour to do their ASI, I'll tell you what I had one client
who at the end of the interview, the interview at HCA, said to the
therapist, oh, w ait a m inute I w ant to change a couple of m y
answers when she told him he was going to be like at level two or
whatever, well let me change a couple of my answers because I
want to be at a lower level. But I want to change a couple of those
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answers, you know, cause they know, if they say too much they're
going to have level 3, cause they already know the program, before
they even walk in the door they know everything. And so, they
walk in the door going I'm going to be a level one because level one
is six months and they're out, you know, six month outpatient,
three months aftercare and then they're probation is discharged
and their felony is discharged. So, yippee, if I can do it in six
months versus a year. But now we've also revamped the treatment
levels so that there's more intensive, they're seen for longer.
They're pretty creative, these guys. --Orange County Outpatient
and Residential Provider
We are given the opportunity to view the ASI. We did at first. We
don't trust the way the CASCs are administering the ASIs. We've
seen too many people that were clearly level three's, that again, and
again, and again, and again, for whatever affinity the assessor had
for the participant continually remained at a one or a two. So we
just said 'that's it with the ASIs', we have our own ASIs in house,
let's bring them in and hold them for a week or two and then
administer the ASI when we know a little bit more about them.
And then we can trust our own ASIs. --Los Angeles County
Residential Provider
In two out of three cases, it's low [the assessment level]. ... I think
the assessment people learned that too. We had people coming in
here on level ones that were screaming addicts and they just
snowed the assessment unit and we see them for two or three days
in group or individual, you know, have five or six encounters with
them and we're going "God almighty". How did you do this? And
they tell us. Oh, I just told them, we figured it out and the ones
who really wanted their freedom but didn't want to do another
treatment program, I mean, they've been treated in jail and they
really thought they knew a lot and in a perfunctory sense, they did.
They knew a lot about drugs, certainly. And that's one of the
reasons why I think curricula driven programs aren't very good
because we teach things that other people have had exposure to in
the jails. So it's not new . —O range C ounty O utpatient Provider
Yeah. And we were talking about what we liked about the ASIs as
far as they're concerned, but the ASI on the Prop 36 is different
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because what they do is they do a DSM diagnosis, and I don't like
that because when I have this client in front of me, what they are
saying on that ASI is not manifesting itself in the client. So I won't
do the treatment plan until 30, they have to be here like 30 days
before I do it, you know, which is a month. And then, I can see
some stuff showing up and it doesn't agree with that ASI because a
lot of times when a client in trauma is sitting in front of you, he's
hiding stuff, he or she is hiding stuff. And there's a lot of stuff that
they're not going to share. — Los Angeles County Residential
Provider
We do another ASI. Some of their ASIs were done initially maybe
when they entered Prop 36 and maybe its taken them three months
to get sentenced to residential so by the time we get them that ASI
may be three months old. Even if its only a week old they
sometimes see the CASC as part of the court and not necessarily
somebody they can trust, so sometimes they give a lot of different
answers even if we do one a week later. -Los Angeles County
Residential Provider
2. Reassessment and Referrals To/From the Assessment Centers
This is partly tied to the issue of the administration of the
Addiction Severity Index as far as the level of addiction at which the client
is initially assessed. However, there are other reasons why a provider
might send a client back to the county for reassessment. Reasons include
that the client is psychotic or has an underlying psychiatric problem that
requires medication that the treatment program is not set up to handle, or
it could be simply that the client has a bad attitude towards treatment and
the program does not w ant h im /h er in w ith their general population of
clients for fear that the attitude will be communicated to the other clients,
causing disruption within the program.
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Basically the only reason they are here is because they got caught.
Some of them were fortunate enough to realize that they needed
change, but basically they only made it here because they got
caught. We screen them for attitude as well as anything else
because then you have your dope dealers who are just trying to
escape jail time or prison time who will say "I'm an addict, give me
a treatment program" and they've never smoked or done drugs in
their lives, they're just dealing them. But they can easily convince
the courts that they have a problem. When they come here, their
attitude is not conducive or healthy for this type of environment
because they tend to spread that poison to everybody else. "I'm
not an addict, I don't need this, and I'm only here because of the
courts." And newer people in recovery are real influential so we
weed them out quickly. You can just go on back and deal with the
judge with your attitude. {Have you ever sent a client back to the
CASC?} I do it all the time. I basically tell them you need to go
back to the CASC, whether it be for a medical issue, or attitude
issue, or positive test, or anything that is determined that we're not
in a position to help you. Then you need to go back and be
reassessed and reassigned because there's an agency somewhere
that can help you but we obviously can't. -Los Angeles County
Residential Provider
I mean, we're a little hesitant to tell the county clinicians what to do
and so we'll give them a chance at whatever assessment level
they've been placed at for a couple of months, one or two months,
we w on't send them back within a week or two unless they are
really off, but they haven't been really off. And then we'll ask for
reassessment. But we do that regularly for clients that have been
here for months who aren't really doing this, so it's like a
buzzword to use. Need reassessment which means they need to be
booted up to something more, and they usually agree, the staff,
because of the volume we do, its not a problem, just the sheer size
of our program. Our staff has all developed really good
relationships with the assessment staff and so they talk to each
other on a daily basis. So formally needing reassessment more is
like this client is really d oin g bad and w anted residential and w hat
should we do. And we'll send them back for reassessment and
they'll reassess. As far as I know about the assessment process,
they use the ASI. There's five assessment staff or something like
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that. Less than 10 at this county, and the clients are sent there
immediately after visiting their probation officer. And then they sit
through this one-hour assessment, and its not computerized yet,
which shocks me a little. -Orange County Outpatient Provider
And what we do, what we've run across is clients that have started
out outpatient and if they didn't succeed outpatient and they ended
up having to get an increase in their level to come to residential.
And that's what, and probably 50 percent of our clients have had
outpatient treatment first and they did not succeed and they ended
up having to go back to get, you know, go to court or to health care
to get reassessed to come into residential. -Orange County
Residential Provider
It seems, the categories seem clear to me in that if they do their
assessment, when someone assess them from the Health Care
Agency, that's when they determine who needs to be in what level.
The people that we've gotten that have been the 30-day or 90 day
type of people, of course in my opinion, they need to be longer in
treatment, but the ones who have been six months or a year, that's
been in line with our program. So I don't know if they always put
the people in the right category, where they need to be. Definitely
people that are in our program need to be in our program. There's
no question like maybe they could do a six-month program, maybe
this is too much for them. Not at all. I don't know about the other
side of it though, I don't know if the people who are in the shorter
programs if that's enough for them. -Los Angeles County
Residential Provider
In the case of this provider, they made it clear to the county that they
wanted the higher-level assessed people to be sent to their program, not
the Level I or Level II client.
Oh, yeah. And the county has invited it. And that's one of the
things w e like about w orking w ith the C ounty. ... A nd they are
saying if you have people who are out there working with these
people think that the level that we have this person assigned at is
really a formula for their failure, let us know. And just put it in
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writing as why you think that, and send it along and we did, often.
We were never denied and we were never trying to goose the
system either. Orange County Outpatient Provider
We send a lot of people back. We'll just discharge them and that's
for any one of a number of reasons, not amenable to services,
continued drug usage, failure to comply with program policies,
we'll first make an attempt through the court report to get the
judge to get their attention, and then we'll just discharge them and
let the CASC deal with them. -Los Angeles County Residential
and Outpatient Provider
And they will call and tell us that they are transporting somebody
and the person will never show up. Well, um, stop here, I want to
get out. You know, they'll get out. And they w on't come in, or
they may be, we'll talk to the assessor and the assessor will say,
well they will be there on Monday at 9 o'clock. They don't show
up. But, an interesting thing happens. They will call you like a
month later, because they have to go to court, so they think you
don't know this, right? So, they'll call and say, "you know, they
sent me over there and I called, and you guys told me to come in
now." They don't know that I'm the one who got their name and I
know who they are. I had to discharge them in the system and I
know who I'm talking to, so I say, "you were supposed to be here
last month, what happened? You were supposed to be here at 9
o'clock." "Well, the judge ..." "No, the judge didn't tell you." I
say "do you have to go to court?" and believe it or not, they will
admit, yeah, I got to be in court and I need to be in a program. No,
you go back to CASC and you have them to reassess you. And
usually what they do now, though is they have to go back to the
court and the judge has to send them back to CASC to be
reassessed, and its on CASC whether they send them back here, or
we have to tell them yes or no. Usually, though, I believe in giving
a person a second, third chance and I will still accept them. -Los
Angeles Residential Provider
Yeah, before y o u even do the adm it [you know ] that they're not
appropriate for this. I've been referred homeless people, people
transient individuals with nowhere to go when they leave here, I
mean, we based our outpatient program criteria on ASAM
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guidelines, you know, and it clearly states that somebody who
doesn't have stable living environment is not appropriate for
outpatient, so we see that. Serious psychosis that's unmedicated,
you know, it eliminates them for appropriateness for this level of
care under ASAM (American Society of Addiction Medicine)
criteria, so it happens. Los Angeles County Residential and
Outpatient Provider
Well, a client, let's take a psych client. He may not be appropriate
for care. There may be too much psych issues, so he may get by the
CASC, but once he comes to us, because the CASC will only see
him for a couple of hours. Once he comes to us and he's in groups
every day, he may not be appropriate for care in this type of
treatment modality. He may be more what they call day treatment,
in a psych facility, he may need some stabilization, and he may not
even be diagnosed. -Los Angeles County Outpatient Provider
Yeah, it happens. We're spending only an hour at a time, and
sometimes they manipulate the system, sometimes we don't get it.
So we kind of figure out, this client is telling us this and that, and
we're going to send him to level one, which is the lowest
outpatient. They get to the other facility and that's when they
spend more time with the counselors, to which they are more open
and .... And that's when the counselor calls me back and says can
we bum p this guy up to level two or something. -Los Angeles
County Residential Provider
I'll tell you sometimes where the difficulty sometimes is, is getting
the true picture of the client because they assess the client for the
severity index but not necessarily for the mental stability of the
client and every once in awhile, they don't ask the right questions
in terms of mental illness. And we've had a few who have come to
us who truly were dually diagnosed and were on psychotropic
medications, so we have learned now to ask up front what
medications they are on before they even get to us, because we're
not a medical facility, we're a social model. We do not have
m edical staff on-site and as a result, w e cannot deal w ith clients
who have severe mental problems. However, if they have some
mental abnormalities, not the word I really want to use, some
mental challenges, we work closely with Harbor, I'm sorry, with
San Pedro Mental Health. -Los Angeles County Residential
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Not very often or we had people who came here and so
misbehaved that we sent them back for a re-referral because we just
couldn't mess with them anymore. And you have to push us really
far because we're also, we take dual diagnosis in addition to, which
a lot of people don't take so we're prepared for, you know, some
bizarre behavior b u t ... Los Angeles County Outpatient Provider
Never sent somebody back once they were referred to us for
reassessment. Have recommended to escalate a level when they
relapse several times what have you to basically elevate their level
from a level two to a level three or level one to level two that's
happened but that's kind our way of trying to adjust people based
upon their performance in the program. -Los Angeles County
Outpatient and Residential Provider
No, I think they're all the same when they come in they're either
they want it or they don't and we know if they do because they're
doing their meetings, they're coming to groups, they're testing
clean, and the ones that don't, come when they want, um, they're
using, they don't do meetings, and you know, but there are certain
things that we can put up with them as far as how many groups
they attend, how many meetings and how many positives, where it
comes to where they're either terminated or their level is bumped
up, or we just discharge them and let the CASC office, you know,
send them somewhere else, or they go to jail—Los Angeles County
Outpatient Provider
Now when people enroll here what I tell them is if you help at any
given point, it's better that you ask for it than not because it's the
difference between you relapsing and not relapsing, and the cost of
it to the client is not going to change. They are still paying what
they are paying and the county is still paying what they are paying,
they just get an increase in services provided to support them in
that. Or if someone relapses and was assessed at Level One and he
tests positive with us and we refer him back to probation but at that
sam e tim e w e'll sit there and say w hat do you w ant from us? D o
you care about your recovery? Do you still want to stay in
recovery? Or, do you not care? And most of them say you know
what, I want to stay in the program, I want to stay in recovery, so at
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that point we'll refer them back to healthcare agency and at that
point healthcare agency will reassess them and either place them
back in our program at a higher level, or remove them from our
program and put them into residential. -Orange County
Outpatient Provider
Now what has happened is that the people who are doing the
original assessment at the end of the assessment they call us and
say I am referring a client to you. Their level, they'll give us the
level and they'll say when can you enroll them? And w e'd actually
set an appointment at the time of the assessment and so, that has
helped in not having people slip through the cracks. But we've had
other providers at the monthly meetings say they weren't getting
those type of calls, and we feel fortunate that we were but that
relationship, I mean, they've been really helpful to us in terms of
saying well if you need this or you need that don't hesitate to call
us. I mean at any point I can call our monitor and ask them what's
going on with a specific client and if he can't well, the key is
communication. Communicating with the probation officer,
because I mean we'll have someone that hasn't attended, missed
two groups or something, and we call the probation officer and say
w hat's going on with so and so and the probation officer says oh I
took him into custody for this and that. If we hadn't done that,
then they would have slipped through the cracks and it would
have been an issue and then, I mean without that communication,
its kind of a required communication between everyone because if
there's a provider that doesn't do that, then they would have
serious problems in terms of reporting or knowing w hat's going on
because you don't want to just say, I mean there's been times early
on in the program where I called and said what's going on with
this client and they go, oh, he's in residential. And we're like, "it
would have been nice to have a call." Now the probation officers,
too, have been informed to call us and let us know so now, I mean I
have probation officers who call and say so and so has had a
positive urine test and just want to let you know. It helps because
what we can do is sit down with the client and say we had an
individual w ith the client or sit d ow n w ith the client and say your
probation officer called and told us that you had a positive test and
kind of get their input on it and at that point we can either increase
or request an increase in treatment or refer them back to healthcare
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agency for reassessment. I think the key to having a successful
program is communicating with everyone. -Orange County
Outpatient Provider
Some programs would also send clients back to the County or
CASC for reassessment as a reward. In this instance, being at a lower
level of treatment would allow the client to get her children back. For
others, it might mean that they would be able to return to employment.
It's when a client has been here for a period of time, she was doing
very well, and had been here for quite some time, in the process of
getting control of her children back, she actually went to her
counselor and asked to be reassessed to step down from treatment
to get a little speedier return of her children so she could start
working. We do allow them to work here, but with her particular
situation, it w asn't convenient. She did very well, she's still in our
outpatient program but they did reassess her and said she was
stable and should not be residential treatment. -Orange County
Residential Provider
As far as clients are concerned, the only problem that we
sometimes seem to have is that, the levels, that they're not assigned
the correct levels of treatment. Because as far as I understand Prop
36 was meant for non-violent first-time offenders and in three
months, you may have a level one that has to be clean for three
months but they've been using their drug of choice for years. You
can't clean somebody up in three months. That's pretty, relapse is
part, sort of part of the condition. And that's kind of hard too
because that first day, I think they're pretty hard on relapsing, you
know, with clients, clients relapse, they're harder on the clients.
We've had, like I said, a level one that should have been a level
two, level three, and when there's, because they do psycho-social
evaluations there. And this person clearly needed mental health
services. That could also be because of the client not sharing that
information with them as well. -Los Angeles County Outpatient
Provider
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3. Program Changes To Treatment Length or Content
Many programs changed the length of their standard treatment
protocol to conform to Proposition 36 requirements. This was
contractually required in order to receive Proposition 36 funding.
Well, we go through our ups and downs. When we first got the
Prop 36 probably just like every other program, we had our ups
and we had our downs because we weren't quite exactly sure. It
was actually our first 90-day program that we took on and we had
to get used to, we had a 42-day program, so it was our first 90-day
program. We got to work with the residents a little bit longer. -
Orange County Residential Provider
The results have been amazing and a lot of that I think can be
attributed to length of stay. The length of time versus our other
programs. In a way, I wish there was some kind of mechanism to
set up to use these successful people. Los Angeles County
Outpatient Provider
4. Facilities issues, purchase, remodel, rent, scheduling changes
Some programs found different types of advantageous
opportunities with the implementation of Proposition 36. One residential
provider was able to obtain additional help from the County to expand
their program facilities, something that may not have happened without
the impetus provided by Proposition 36.
If it hadn't been for them, we wouldn't have had to support to get
the conditional use permit from the city, for one thing. So they
played a big part in our getting that building ready. Orange
County Residential Provider
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Not recently. We're looking though. And the reason why is
because we want to be able to have more. We want to be able to
have more room for more clients, because right now we only have
so much space. We're about to move, we already have another
building bigger so we can take in more Prop 36 clients but right
now we're only, we limit ourselves because of the space that we
have but we really want to make it so we can take more. -Los
Angeles County Outpatient Provider
Actually, we have. We've changed our schedule. Before Prop 36
we actually only provided classes in the afternoon. Now, and I've
got a copy of the schedule here, we have morning and evening
classes. So, and we separate it out. -Los Angeles County
Outpatient Provider
5. 'No Show' Clients
Two main types of no-show clients were reported by drug
treatment providers. One type of "no show" simply never showed up
from the county assessment center. The program received the telephone
call, or e-mail, or fax indicating that the client was being referred to the
program and should be expected to show up on a specific date, but the
client never appeared. These clients also seldom called to reschedule their
appearance at the drug treatment program. A second type of "no show"
client was more frequently reported by outpatient providers than by
residential providers. These clients showed up to be admitted to the
program, but after completing the initial paperwork, were not seen again.
In these outpatient programs, that meant that they were not showing up
for group or individual counseling sessions or for their 12-step
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meetings. These types of "no shows" were much more frequent among
the outpatient programs because, if a client showed up for a residential
program, once there, it was much more difficult for him /her to leave the
program. Outpatient programs are maintained for clients who have their
own housing, so the program has much less control over their attendance
at treatment-related appointments.
Yes. Not a problem, but I mean, yeah, there's an issue. It happens
and it happens regularly. I would say for our residential program
we are probably running at about, I haven't got data at my
fingertips, but maybe a fifty percent no show rate and then our
outpatient program is probably running at about a, you know,
much less, 25 percent no show rate. Los Angeles County
Outpatient and Residential Provider
However, if it is necessary, for instance, the cost of no shows, what
it is costing in wasted time, wasted money, that the staff gets every
month. ... one of the CASCs that we deal with [gave us] a figure of
30 percent no shows as the norm. Our no shows for instance, last
month, were 17 percent because we really put some muscle into ....
But it was costing us and it was keeping people who needed
treatment out of treatment because we were full. Los Angeles
County Outpatient Provider
Yeah, it happens. I had one yesterday, so maybe five percent ten
percent of referrals don't show up. Los Angeles County Outpatient
Provider
It's a good percentage of them will be sent here, left to come on
their own and never make it. I understand, they're addicts ... Los
Angeles County Residential Provider
Yes, we probably get somewhere ... it's as high as 20 percent. What
will happen is they'll come just for their assessment, and that seems
to be a trend, where they come just for the initial, so they sort of get
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the heat off the court system for awhile and they get a little bit
more time, um, and those are the ones that aren't serious at all,
they'll get a little reprieve per se. So they'll come to their
assessment, they'll get assessed, and they won't show up anymore.
Well, what they've done is they get about a two or three-month
reprieve but it makes it very hard for them when they go back to
the CASC if they get caught. Because what will happen is that a
bench warrant will be generated eventually, um, they'll be arrested,
they'll be put back and they'll have to go to a CASC again. At the
same time, what they may be doing, they may be eating up that
time that Prop 36 is available, part of those 18 months that I was
talking about earlier too. They may be eating up some of those
days. Los Angeles County Outpatient Provider
Ugh! Yes! We have a lot of problems with no shows. We have a
lot of problems and the thing is that they are wise enough now to
know just how many they can miss without getting discharged.
Because it gets around, and urine testing, they know that its much
better to not show up than to show up and test positive. A no
show is not nearly as severely penalized by the court as a positive
test. -Los Angeles County Outpatient Provider
So, w e're losing about 30 percent on relapse, no shows, related
problems, difficulties, and violations, whatever. -Los Angeles
County Outpatient and Residential Provider
Oh, yeah. A lot of them. We do intakes on them and they just get
what they want because they got their paper to go to court the next
day or whenever they go to court that they are enrolled and they
never show back up. [What do you do when that happens?] Well,
we just discharge them. We keep their file open because we can't
keep them open more than 30 days. We keep them open for maybe
the week or two to see if they do come back and we try to work
something out with them and if they don't, then we just have to
discharge them because we can't. We have to make room for
people that are waiting. -Los Angeles County Outpatient Provider
Yeah, we have plenty of no shows. I mean I can't, I wouldn't say its
fifty percent of them but maybe 20 percent of them don't show up.
Los Angeles County Outpatient Provider
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Yeah, we have a lot of the ones that come, not very many that don't
show up from CASC, a small percentage. They come, they enroll in
the program and they show up when they want to show up. -Los
Angeles County Outpatient Provider
They w on't even come for the intake. The people who do show up,
stay. They come here and they like it. We treat them appropriately
because some of these people have been treated very badly for
many years with being in jail, incarcerated, and prison and so forth,
and they're not judged and I think once they get here and they
realize that, they stay. The problem we have is the people who
don't come at all and I'm not sure, I couldn't give you a percentage,
but its not very big, but the people who come, stay. It's the people
who don't show up at all, we don't know where they went or
what's going on with them. -Los Angeles County Outpatient
Provider
6. Receiving clients from multiple CASCS
After the initial startup period, most programs reported working
very well with the CASCs that referred clients to them. Most programs
reported working with one or two main CASCs, but some programs that
got referrals from CASCs outside the county where their program was
located experienced additional difficulties because the procedures
associated with Proposition 36 varied from county to county.
Usually the county, Los Angeles County, we have no
miscommunication on any problem because of this meeting that we
have every other month. But for the outside counties they got their
own protocols, so it took a while for us to understand Orange
county, Riverside county, San Bernardino county, Kern county, San
D iego, so it took a w hile to try to catch up to w hat they do w ith
Prop 36. -Los Angeles County Residential Provider
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7. Pressure from the Counties
A few, not many, of the programs indicated that they were under
pressure from the county to take more Proposition 36 clients than they
could really accommodate. One provider explains:
No, um, its, you know, I would say for our program, its been well
funded. In fact they've actually made allocations a couple of times
that were beyond our capabilities. There was a misunderstanding
about what we could do at this location, so they allocated based on
an assumption that we could do this, and we had to go back and
explain to them, no, we can't do that here, we only have this much
available space. Los Angeles County Outpatient Provider
Summary of the Findings From Phase I
Some support was found for the pre-specified hypotheses. For
example, the treatment programs' prior experience with criminal-justice-
involved clients had an impact on their programs' Proposition 36
experience, but only for those few programs that had little prior
experience with this population. These programs tended to be outpatient
providers with experience with individuals remanded for education
under the drunk driving laws; they made a decision to diversify their
funding and client portfolios by getting into outpatient treatment through
Proposition 36. The fact that outpatient treatment was for Proposition 36
offenders assessed at the low est level of addiction did not m ean that these
clients were comparable to drug driving clients. Programs had many
challenges adapting to working with even these low-level drug
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offenders. Programs that did not have a formal, hierarchical reporting
structure in place for managing Proposition 36 activities did not report
more or fewer problems than other programs with such structures. While
the administrative structures of some of the smaller programs were
complicated, with many staff members wearing several "hats" with
respect to job duties, staff within the programs appears to have adapted to
the structure of these programs.
The hypothesis that participation in county-provided training
activities affected the drug treatment programs' experience of Proposition
36 was supported by the findings. Most providers were enthusiastic
about the training. Those providers that did not attend training, however,
managed to obtain most of the basic information they needed to get the
Proposition 36 program up and running within their organizations. The
counties provided such things as telephone help lines for support on
technical questions in Los Angeles County; and, in Orange County, both
telephone and on-site assistance was provided. This "outreach" effort on
the part of the counties enabled most providers to obtain needed
information on procedures.
The findings w ith respect to the values reflected in Proposition 36
were interesting. Many programs saw Proposition 36 as a great
opportunity for drug treatment overall as might be expected. Other
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programs, while less than enthusiastic about some of the provisions of
Proposition 36, applied for funding and joined as organizational actors
with the explicit purpose of promoting changes to Proposition 36. These
programs saw this as an opportunity to help Proposition 36 evolve into a
program they could support.
One of the strengths of Proposition 36, as evidenced by the findings
for hypothesis 5, was its incorporation of pre-existing drug treatment
practices, principles and conventions into the treatment plans required for
Proposition 36 participants. It was generally felt that use of the existing
12-step meeting infrastructure already in place was appropriate for
Proposition 36 clients. The addition of an aftercare component was
another positive aspect of Proposition 36 perceived by providers.
Programs' perceptions of clients coming into treatment strongly
influenced their Proposition 36 experience. Programs that initially had
negative experiences with clients found ways to manage them, such as
creating a separate treatment track for them to keep "toxic" clients away
from the other client populations, or by finding the means and reasons for
sending the clients away from the program and back to the county
agencies for reassessm ent.
The most frequently mentioned aspect of Proposition 36 that was
resisted by providers concerned the Addiction Severity Index
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instrument. Most programs felt suspicious of the ASIs completed by the
county or assessment centers; they felt that either the individuals
conducting the intakes and ASIs were not savvy to the manipulations of
the clients or they felt that the clients were being dishonest during the
intake and assessment process. This belief in the unreliability of any ASI
done outside of the treatment center itself provided a crucial basis for
programs to resist clients that they felt were not appropriate for their
programs. The counties, in turn, were very open to the notion of
reassessment of clients and their placement in different programs, so for
the most part, assessment—reassessment worked to enable the programs
to exercise some control over who was coming into their programs.
Within the theoretical framework outlined in Chapter 2, activities
could be said to fall into two categories: compliance activities and
resistance activities. Compliance activities identified in the Phase I
interviews include attending informational meeting held by the counties;
changing the length of the programs' standard treatment modality to
conform to Proposition 36 standards (minimums); changing the hours that
groups and counseling sessions meet to accommodate Proposition 36
clients; obtaining training on Proposition 36 procedures, including use of
the county's database for tracking clients; hiring new staff; increasing the
caseloads of existing staff; acquiring additional space; upgrading
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existing computers or purchasing new ones; bringing concerns to the
county's attention; and taking on more Proposition 36 clients at the
county's request.
Resistance activities identified include urine testing during the first
year of Proposition 36 activities, before the governor allocated funds and
while it was still officially not a sanctioned Proposition 36 activity;
completing additional Addiction Severity Index or other psych/social
evaluations of clients to supplement the ones done by the county
assessment centers, or to replace the ones done by the county due to their
perceived uselessness; sending clients back to county assessment centers
for reassessment and placement with another provider; creating a separate
treatment track for Proposition 36 clients, especially when done because
Proposition 36 clients were perceived as "toxic" to the other clients.
The extent of engagement in compliance and resistance activities
was the focus of the telephone interviews developed under Phase II of this
project. That is the subject of the following chapters.
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Table 7. Compliance and Resistance Activities Identified in Phase I
Interviews
Compliance Activities
Attending county meetings
Attending training (on shared data system, etc)
Hiring staff
Creating a separate TX track
Acquiring additional space
Increasing caseloads of staff
Acquiring additional space
Changing length of TX
Changing hours that groups/counseling sessions meet
Upgrading/purchasing computers
Bringing concerns to county's attention
Increasing the number of clients
Creating a separate treatment track only for Prop 36 clients*
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Resistance Activities
Urine testing despite lack of funding (first year only)
Re-doing ASI or other assessment
Sending clients back to CASCs
Creating a separate treatment track only for Prop 36 clients*
*both a compliance and a resistance activity, depending on context
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Chapter 5
Phase II — Telephone Interviews
In Phase I of this research, the reactions of drug treatment
providers to implementation of Proposition 36 were explored through in-
depth, semi-structured on-site interviews with key informants from a
sample of programs in Los Angeles and Orange counties. Telephone
interviews were undertaken in Phase II of the research to determine if the
findings from these initial interviews would generalize to a larger sample
of drug treatment providers. The focus of the interviews was the same as
that for the Phase I interviews: what did drug treatment providers do in
reaction to implementation of Proposition 36? Because compliance and
resistance activities were identified from the Phase I interviews as being
prominent in drug treatment providers' responses to Proposition 36
implementation, questions concerning specific compliance and resistance
activities were part of the telephone interview. The programs selected
were a convenience sample of drug treatment providers from six counties
in Southern California; however, the respondent invited to complete the
interview from each program was a key informant (Proposition 36
coordinator or other know ledgeable staff person) sim ilar to the Phase I
interviews.
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A. Instrumentation
The data set consists of data from telephone interviews with 72
drug treatment programs in six counties in Southern California. All data
were collected during June through September 2003. The telephone
survey instrument was developed using information gathered from the
in-depth interviews conducted at drug treatment programs in Southern
California counties. The telephone survey instrument can be found in the
appendix.
The telephone survey took approximately 15 minutes to
administer. The first questions were intended to gather demographic
information on the following aspects of the drug treatment program:
whether it offered outpatient or residential services under Proposition 36
(or both); whether the program offered aftercare services under its
Proposition 36 contract; the number of client slots available in each of the
outpatient or residential modalities for Proposition 36; the total number of
staff members who worked at the program at the time of the interview;
the total number of staff who were directly involved in work on the
Proposition 36 contract; whether the program had hired any new staff to
w ork on Proposition 36; if the answ er to this question w as 'y e s/ then a
follow-up question concerning the type of staff position that the program
hired was asked, (counseling staff, intake staff, administrative staff or
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some other job classification); the year that the program received its first
Proposition 36 client; whether or not the program has regularly scheduled
staff meetings; and how often these meetings are held.
The next section of the questionnaire elicited information on the
types of changes the program may have made to its regular treatment
program activities as a direct result of obtaining funding under
Proposition 36. Possible program changes the treatment provider may
have instituted include: creating a separate treatment track for Proposition
36 clients; changing the hours or days that groups or counseling sessions
meet to accommodate the Proposition 36 clients' needs or schedules;
acquiring additional space to accommodate Proposition 36 clients and
activities; changing the length of the program 's standard treatment
modality to conform to the requirements of the Proposition 36 legislation;
or increasing the caseloads of case management or counseling staff to
accommodate Proposition 36 clients.
The third section of the questionnaire was a series of statements
that the respondent was asked to rate on a one (1) to five (5) scale, with 1
being total disagreement with the statement and 5 being very strong
agreem ent. The statem ents in this section included topics such as the
adequacy of training that program staff had obtained on managing the
Proposition 36 contract; confidence in the accuracy of the intake
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assessments done by the County or the Center Assessment Centers when
placing the clients; problems with 'no show' clients; the degree to which
clients understand the expectations of their treatment under Proposition
36; financial issues concerning administration of the Proposition 36
contract; and interactions between the program and county staff. Three
questions, also employing a 1 to 5 scale were used to determine the
treatment philosophy of the program. One such question, "On a scale of
one to five, with five being very important and one being not very
important, how important are professionals with master's degrees or
Ph.D.s for service delivery in this program?" was designed to capture the
degree to which the program relies on individuals with professional
credentials. Another, "On a scale of one to five, with five being very
important and one being not very important, how important are ex
addicts for service delivery in this program?" attempted to determine the
degree to which the 12-step philosophy plays a role in program service
delivery. Finally, the question, "On a scale of one to five, with five being
very important and one being not very important, how important is
sobriety or complete abstinence from drug use for clients?" attempted to
capture the ph ilosop h y of total abstinence in program service delivery.
The final section of the interview elicited information on the
accreditation status of the program, and the background of the
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respondent, including their gender, primary role at work, and how many
years experience they had in working in substance abuse treatment,
including how long they had worked at the program where they were
currently employed. Table 8 illustrates the correspondence between the
Phase II telephone survey instrument and the issues identified as
important to Proposition 36 implementation in the Phase I interviews.
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Table 8. Translating Phase I Findings into Telephone Survey Items
Variable Phase I Question Phase II
Lack of experience w / criminal
Justice-involved clients*
Organizational structure*
County provided training /info*
Treatment values/sobriety
Professionalism*
Implementation activities/
Financial*
Perceptions of clients*
Q25
Total staff; total Prop 36 staff;
total clients; types of services; any
new hires;
Types of new hires; hold staff
meetings;
Frequency of staff meetings
Q3; Q13; Q16; Q21
Q15; Q29; Q30; Q31
Separate track; changed hours;
increased caseloads; Q2;
Q U ; Q14; Q17; Q18; Q20; Q22;
Q23
Q8; Q9; Q12; Q26; Q27
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Table 8. Translating Phase I Findings into Telephone Survey Items
(continued)
Variable Phase I Question Phase II
ASI unreliability*1 1 ' Q7; Q33
Reassessments/CASCS referrals** Q ll; Q28
Changes to treatment program length** Changed length
Facilities** Additional space
No-show clients** Q5
Multiple CASCS** Q32
Pressures from County** Q4;Q6
*pre-specified hypotheses from Phase I
**content analysis findings from Phase I
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B. Participating Drug Treatment Programs— Sampling
Six southern California counties were identified as potential areas
for the telephone interviews. Drug treatment programs in each county
were identified through the State of California Alcohol and Drug Program
lists of "Licensed Residential Facilities an d /o r Certified Alcohol and Drug
Program." These lists are published on the State of California Alcohol
and Drug Program web site.
Initial telephone contact with each program was made for the
purpose of determining whether the program was a Proposition 36
provider or not. A second list was developed for each county after this
first round of telephone calls, comprised solely of those programs that had
indicated that they were providing Proposition 36 services. Programs
indicating that they did not provide Proposition 36 services had no further
contact.
The telephone survey using the instrument developed for this
purpose was a purposive sample of those programs in each county
identified as Proposition 36 providers. Telephone contact was again made
with each program, with the interviewer identifying herself as a graduate
student in public adm inistration and the purpose of the survey. The
interviewer asked to speak with the Proposition 36 coordinator. In most
cases, the programs readily identified such a person to speak to the
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interviewer. In some cases, there was no one matching that title in the
program, but the interviewer was referred to the Proposition 36 case
manager or intake coordinator. In some cases, the interviewer was
referred to either the Executive Director or Clinical Director, if the person
originally identified as the Proposition 36 coordinator did not feel he/she
could respond to the interview questions without prior approval of
executive management. As in the Phase I interviews, the respondent was
a key informant, selected because he/she was knowledgeable about
Proposition 36 and its implementation.
Once an individual at each program had been identified who was
knowledgeable about Proposition 36 activities within that program, and
who agreed to complete the interview, the interviewer reviewed the basic
rules of the interview: 1. That all responses to interview questions would
remain confidential; 2. That neither the respondent nor the program
would be identified by name in any publication or report related to the
interview; 3. That the respondent was free to refuse or decline any of the
interview questions; and 4. That the respondent should indicate those
questions to which he /she did not have an answer and that question
w ou ld be skipped. The table below sh ow s the breakdow n of program s by
county that participated in the telephone interview.
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Table 9. Telephone Interview Respondents by County (N = 72)
County Total Respondents %
Kern 8 12
Los Angeles 39 55
Orange 5 7
Riverside 14 20
San Bernardino 5 7
Santa Barbara 1 2
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C. Hypotheses
Hypotheses for the telephone surveys were based on the data
collected from the semi-structured interviews in Phase I. They are:
HI: An association will be found between outpatient and residential
programs with respect to Proposition 36 compliance activities.
During the Phase I interviews, differences were noted between the
type of program and the type of compliance activities. For example, it is
easier for an outpatient drug treatment program to change the hours that
groups or counseling sessions meet, because their clients do not live
together in a residential setting. For residential providers, because their
clients live together in a residential setting, the clients' fulltime activity is
drug treatment. Hours for groups and individual counseling sessions can
be set, and there is no need to change them to accommodate each client
that may enroll in the program.
H2: There will be no association between type of program (outpatient
compared to residential) with respect to Proposition 36 resistance
activities.
Findings from Phase I suggest that the main resistance activities
include com pleting an additional A ddiction Severity Index (ASI) or other
psychological- social assessment due to distrust of the assessments done
by the counties or assessment centers, and sending clients back for
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reassessment. Since both residential and outpatient drug treatment
providers have a vested interest in receiving clients that are appropriate
for their respective programs, it was hypothesized that there would be no
difference between the type of program and their use of resistance
activities to limit their client populations to those clients that they feel are
appropriate for their programs.
H3: Compliance and resistance activities will be associated with overall
experience of Proposition 36.
In the Phase I interviews, activities initiated by programs as a result
of Proposition 36 implementation were identified and classified as
compliance or resistance activities. The theoretical framework presented
previously in Figure 1 identifies compliance and resistance activities as
directly impacting the programs' overall experience of Proposition 36.
This hypothesis directly tests the theoretical relationship between
compliance and resistance activities and overall experience of Proposition
36.
H4: Staff perceptions of clients will be associated with the programs'
overall experience with Proposition 36.
In the Phase I interview s, perceptions of clients w ere im portant
elements in how Proposition 36 providers reacted to implementation
activities. Those programs that perceived clients as being manipulative
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towards staff or "toxic" to other clients responded with strategies to
manage these clients. Programs that perceived Proposition 36 clients as
being confused by Proposition 36 requirements and as being
inexperienced in dealing with the conflicting demands of the criminal
justice system and the drug treatment programs, also adopted strategies
to handle clients. It was hypothesized that these perceptions of clients
impacted the drug treatment programs' overall experience with
Proposition 36.
H5: Perceptions of Proposition 36 clients are associated with
resistance activities.
Resistance activities include reassessing clients within the drug
treatment program, or sending the client back to the county or assessment
centers for reassessment. The Phase I interviews revealed that programs
routinely sent clients back for reassessment for a number of reasons,
including the perception that they were not serious about treatment or
recovery. Resistance activities are hypothesized to be one of the strategies
used by the drug treatment providers to ensure that they were working
with clients they perceived as being potentially the most responsive to
drug treatm ent and the m ost adaptive to the program s' specific
environment.
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H6: Proposition 36 financial concerns are associated with compliance and
resistance activities among drug treatment providers.
In the Phase I interviews, those providers that expressed difficulties
with the payment structure of Proposition 36, such as the fee-for-service
payment agreements that were in use in some counties for the outpatient
programs, were also less likely to be engaged in compliance activities,
such as attending training activities. These programs expressed concerns
that training activities were not covered by the fee-for-service funding and
required non-reimbursed staff time to attend them. It was hypothesized
that those programs with issues regarding payment for the services they
provided will be less likely to engage in compliance activities. Programs
that do not have issues with the funding of Proposition 36 activities will
be more likely to engage in compliance activities and less likely to engage
in resistance activities.
H7: Differences in overall Proposition 36 experience will be associated
with the amount of experience that programs have with Proposition 36
activities as indicated by the year in which the program received its first
Proposition 36 client.
It w as h ypothesized that program s that received their first
Proposition 36 client in 2001, the first year of Proposition 36 funding, will
report better overall experience with Proposition 36 than programs that
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set up their Proposition 36 programs more recently. In the
implementation of a new program of the magnitude of Proposition 36,
providers that were involved from the beginning will have a greater
amount of experience working with the counties than programs that only
recently received funding for Proposition 36 activities.
H8: Program values will be associated with compliance and resistance
activities regarding Proposition 36.
Program values can be embodied in a number of characteristics,
including the emphasis the program places on the use of professionals
compared to ex-addicts in service delivery; the emphasis the program
places on complete abstinence from drug use during the treatment
experience as compared to an orientation that is more oriented to harm
reduction; and the importance placed on the use of urine testing as a
treatment tool.
D. Data Analyses
All data analysis was performed using the SAS System. The first
analysis included the generation of simple frequencies to describe the data
set of programs and individuals that responded to the telephone survey.
This included frequencies of program type (residential or outpatient or
both); frequencies of the size of the programs based on the total number of
staff employed by the program; frequencies of whether the programs
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did or did not hire new staff to work on the Proposition 36 contract;
frequencies of the year in which programs received their first Proposition
36 client; and frequencies for whether programs did or did not implement
any of the five changes to their program as a direct result of Proposition
36.
Testing of hypotheses one through eight were tested using three
standard statistical tests: Pearson correlations, chi-square analysis, and
multiple linear regression. Table 10 shows the hypothesis number, the
variable or indicator used to measure the constructs of the hypothesis, and
the statistical test used to test the relationship specified in the hypothesis.
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Table 10. Hypotheses, Indicators, and Statistical Tests
Hypothesis Indicator Statistical Test
HI: Differences will be
Found between type of
Provider and compliance
Activities
H2: No association will be
Type of program
hired staff; track;
hours; TX length;
caseload; space
Type of program;
Found between type of provider ASI (Q33)
And resistance activities
H3: Overall experience is Q39; hired staff; track;
Associated with compliance/ hours; TX length;
Resistance activities
H4: Perceptions of clients
caseload; space
Q8;Q9; Q12; Q26;Q27
Will be associated with overall Q39
Experience of Proposition 36
H5: Perceptions of clients will
Be associated w ith resistance
Activities
Q8; Q9; Q12; Q26; Q27
Q33
X
X
Correlation/
regression
Correlation
Correlation
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Table 10. Hypotheses, Indicators, and Statistical Tests (continued)
Hypothesis Indicator Statistical Test
H6: Financial concerns Q ll; Q20; Q22; Q23; Correlation
Are associated with hired staff; track; hours;
compliance / resistance TX length; caseload;
activities space
H7: Overall Proposition 36
Experience will be Q39; year Correlation
associated with experience/
Year program received its first
Prop 36 client
H8: Program values Q l; Q15; Q29; Q30; Q31 Correlation
will be associated hired staff; track; hours;
With compliance/resistance TX length; caseload; space;
Activities Q33
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Correlation coefficients were used to determine if an association
exists between variables. Correlations indicate whether a relationship
exists between two variables and the strength of that relationship. The
Pearson correlation technique was used to examine the relationships
between two or more variables and these findings are presented in the
form of a correlation matrix for each of the hypotheses where correlation
was used (Kuzma & Bohnenblust, 2001).
Chi-square tests of differences between proportions were used to
determine differences between categorical variables, such as differences
between outpatient and residential programs, and each of the compliance
and resistance variables. The compliance and resistance variables are
gathered as yes/no and coded as 1 for 'yes' and 0 for 'no'. Chi-squares
were run between the compliance and resistance variables and the type of
program reporting those that did or did not institute such a programmatic
change as a result of proposition 36.
A linear regression model was developed using the overall rating
the program gave to its experience with Proposition 36 ("On a scale of 1 to
10, with 10 being the best experience possible and 1 being the worst
experience possible, h o w w ou ld you rate your program 's experience w ith
Proposition 36 overall?) as the dependent variable. In addition to
hypothesis testing, Pearson correlations were employed to determine
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the strength of the correlations that exist between independent variables.
In some cases where linear regression is used, problems can occur with
model building if independent variables are more highly correlated with
each other than with the dependent variable of the analysis (Schlotzhauer
& Littell, 1997). Variables were reviewed for their correlations with the
dependent variable and the other independent variables. Independent
variables that were highly correlated with other independent variables
were noted and carefully tested in the multivariate models to ensure that
their high correlations with each other did not cause multicollinearity
(which can effect the precision of model estimation) in the multivariate
models (Fox, 1991; Schlotzhauer & Littell, 1997).
Results of the Telephone Interviews
Program Description
The majority of programs interviewed by telephone, like the
programs interviewed on-site for Phase I, were experienced in the
delivery of Proposition 36 services. The majority received their first
Proposition 36 client in 2001, the first year that Proposition 36 was in
place. A few of the programs had received their contracts with counties
for delivery of Proposition 36 services in a subsequent year. The table
below shows a breakdown of the programs by the year in which they
received their first Proposition 36 client. Six of the respondents were
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unable to say when the program had received its first Proposition 36
client. The majority of programs interviewed by telephone, like the
programs interviewed in Phase I, were outpatient providers.
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Table 11. Telephone Interviews: Participating Programs by Year and Type
Year Received
First Prop 36 Client
n %
2 0 0 1 51 76
2 0 0 2 13 19
2003 3 4
Type of Program
Outpatient only 41 59
Residential only 14 2 0
Both residential and
Outpatient 15 2 1
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Programs were asked whether they also provided aftercare services
to Proposition 36 clients. Aftercare services were instituted later as part of
Proposition 36 services as a way of maintaining contact with clients after
they had finished their basic Proposition 36 treatment and to assist them
in maintaining their sobriety. Aftercare usually involved attendance at
group meetings at the treatment program once or twice per week, in
addition to maintaining regular attendance at 1 2 -step meetings.
Of all programs interviewed, 58 of the 72 total interviewed said
that they provided aftercare services. Fifty-three of the programs
providing any outpatient services indicated that they also provided
aftercare services for Proposition 36 clients. The other five programs
providing aftercare services were residential programs.
There was some variety in the size of the programs represented by
the respondents to the telephone interview. For the outpatient programs,
the range of total clients was from two to 200. For these programs, the
mean number of clients was 55, the median was 40 and the mode was 50.
For the residential programs, the range of total clients was from one client
to 2 0 clients; the mean for residential programs was 8 clients, with a
m edian of 7 and a m ode of 7. O utpatient program s had greater num bers
of staff overall than the residential programs. Overall, programs reported
from one to 1 0 0 staff.
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Ninety-seven percent of programs indicated that they held
regularly scheduled staff meetings. The majority of programs ( 6 8 percent)
indicated that staff meetings were held on a weekly basis, followed by 2 0
percent of programs that indicated staff meetings were held on a monthly
basis. Less frequently mentioned were staff meetings held bi-monthly and
daily.
The majority of programs said they spoke with their county
monitors less than quarterly (84 percent). Responses to this item were
very highly correlated with the county that the respondent was from.
Programs in Los Angeles County were far less likely to report that they
had spoken to their county monitor recently. Respondents from Orange
County were more likely to report daily or weekly communication with
their county monitors. Respondents from the other counties were more
like Los Angeles County than like Orange County in indicating less
frequent contact with their county program monitor.
There was some variation in the total number of assessment centers
that programs received Proposition 36 clients from. Respondents
indicated that they received clients from a range of one assessment center
to up to 10 different assessm ent centers. The m odal response w as four
assessment centers, with 30 percent of programs giving this response
when asked.
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Respondent Description
The majority of respondents to the telephone interview were male
(54 percent). The majority of these described their primary work role as
"administrative" (32.8 percent) followed by those who described their
primary work role as doing "everything" (14.3 percent). Fourteen percent
described their primary work roles as "case managers" and another 14
percent described their work roles as "supervisor." There was a wide
range of total years working in substance abuse reported by the
respondents. The range was from 1 to 35 years, with a mode of three
years and a mean of 1 0 years and a median of seven years.
In response to the questions, "How long have you worked at your
current program?" there was also a wide range of experience. The range
of answers was from one to 2 2 years, with a mode of one year, a median of
three years, and a mean of 5 years of tenure at the program where they
were currently employed.
Response Frequencies
In response to the questions concerning hiring of new staff to work
on Proposition 36, the majority of programs reported that they did not
hire n ew staff. For those program s that indicated that they had hired n ew
staff, the most frequently mentioned staff position that was hired to work
on Proposition 36 was counseling staff (20 programs hired counseling
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staff), followed by "some other position" (nine programs hired this type of
position), followed by administrative staff (9 programs) and intake staff (2
programs).
The majority of programs indicated that they had made changes to
their operating procedures to accommodate Proposition 36 requirements
or client needs. The majority of programs indicated that they had
established a separate treatment track for Proposition 36 clients, that they
had changed the hours that groups or counseling sessions were held to
accommodate Proposition 36 clients, that the program had changed the
length of its standard treatment modality to conform to Proposition 36
requirements, that the program had increased the caseloads of counseling
or case management staff to accommodate Proposition 36 clients, and that
the program had acquired additional space, either through rental or
purchase to accommodate additional Proposition 36 clients. Table 12
summarizes the results for compliance and resistance activities. Summary
statistics of all the variables can be found in Table 13.
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Table 12. Telephone Interview Results: Compliance and Resistance
Activities
Activity Total "Yes" % "Yes" Type
Hired new staff 32 45.7 Compliance
Separate treatment track
for Prop 36 clients 40 57.1 Compliance
Changed hours groups/
counseling sessions met 39 55.7 Compliance
Changed program TX length 36 52.9 Compliance
Increased caseloads/counselors
and case managers 42 61.0 Compliance
ASI or other assessment 44 65.7 Resistance
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Table 13. Summary Statistics on all Variables
Variable Mean SD Min Max
Outpatient - - l=yes 2 =no
Resident - - l=yes 2 =no
Aftercare - - l=yes 2 =no
Prop 36 clients in outpatient program 55.00 47.28 2 0 0
Prop 36 clients in residential program 8.18 4.39 1 2 0
How many total program staff 11.85 13.73 1 1 0 0
How many total dedicated Prop 36
staff
5.89 4.43 1 2 0
Has the program hired new staff - - l=yes 2 =no
Hired A (counselors) - - l=yes 2 =no
Hired B (intake) - - l=yes 2 =no
Hired C (admin) - - l=yes 2 =no
Hired D (other) - - l=yes 2 =no
Year received first Prop 36 client - - 2 0 0 1 2003
D oes the program hold staff m eetings - -
l= y e s 2=no
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Create separate track for Prop 36 - - l=yes 2=no
Change the hours that counseling - - l=yes 2=no
sessions met
Acquire additional space - - l=yes 2=no
Change the length of treatment - - l=yes 2=no
Increase the caseloads - - l=yes 2=no
Q11 am confident that the county is 3.97 1.006 1 5
sending clients who are appropriate
for our program
Q2 The paperwork required for Prop 2.24 1.37 1 5
36 does not take much time
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Q3 Our staff have received adequate 4.00 1.09 1 5
training on the database used for
tracking clients
Q4 We have felt some pressure to take 2.11 1.34 1 5
more clients than we can
accommodate
Q5 We routinely have a problem with 3.37 1.26 1 5
'no show' clients
Q6 The majority of our total program 2.54 1.53 1 5
slots are now filled by Prop 36 clients
Q7 We routinely use the ASI in 4.179 1.29 1 5
treatment planning
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Q8 Prop 36 clients know that they 2.98 1.47 1 5
have 3 tries at recovery when they
come into the program
Q9 Prop 36 clients do not understand 3.24 1.40 1 5
the requirements for attendance when
they come into the program
Q ll Reimbursement levels cover the 3.08 1.48 1 5
costs of the Prop 36 clients
Q12 Prop 36 clients are not initially 2.71 1.09 1 5
interested in recovery
Q13 We have upgraded computers or 3.81 1.25 1 5
purchased new ones since Prop 36
began
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Q14 We have not made any treatment 2.23 1.45 1 5
program changes for Prop 36
Q15 Prop 36 treatment intensity is 3.67 1.36 1 5
sufficient and realistic
Q16 Our program brings all concerns 4.14 1.08 1 5
to the County's attention
Q17 Impossible to run a treatment 4.30 1.27 1 5
program without urine testing
Q18 Prop 36 clients should not have to 2.35 1.59 1 5
pay toward their treatment costs
Q19 We share problems and solutions 3.80 1.26 1 5
with other treatment providers
Q20 Invoices are seldom paid on time 2.21 1.31 1 5
by the C ounty
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Q21 We have invested a lot in staff 3.75 1.04 1 5
training for Prop 36
Q22 We have used Prop 36 to replace 1.72 1.08 1 5
other funding streams
Q23 Many costs of Prop 36 are not 3.42 1.38 1 5
covered by county funding
Q24 We have a high turnover rate 1.81 1.28 1 5
among our counseling staff
Q25 Our agency had little criminal 1.54 .96 1 5
justice experience
Q26 There is no difference between 2.86 1.48 1 5
our other clients and Prop 36 clients
Q27 Prop 36 clients more likely to be 2.46 1.27 1 5
dually diagnosed
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Q28 We have never asked the county 2.68 1.58 1 5
to reassess a Prop 36 clients
Q29 How important are masters' 2.94 1.33 1 5
degrees and Ph.D.s
Q30 How important are ex-addicts 4.01 1.09 1 5
Q31 How important is complete 4.80 .55 2 5
sobriety for clients
Q32 How many CASCs do you 3.30 1.93 0 10
receive clients from
Q33 Psych/social evaluation in 1 2
addition to the ASI done by County
Q37 Years working in substance abuse 10.07 8.16 1 35
treatment
Q38 How long working at this agency 5.16 5.14 1 22
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Table 13. Summary Statistics on all Variables (continued)
Variable Mean SD Min Max
Q39 Rate your overall experience
With Proposition 36 7.55 1.92 2 10
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Results
Contingency table or chi-square analysis of the difference between
proportions was used to test hypothesis 1 that an association would be
found between the type of treatment provider (residential or outpatient)
and compliance activities.
Chi-square analysis was used to determine significant differences
in proportions between the six compliance variables (hiring new staff,
creating a separate treatment track for Proposition 36 clients, changing the
hours that groups or counseling sessions met, acquiring additional space
through rental or purchase for Proposition 36 activities, changing the
length of the standard treatment modality and increasing the caseloads of
counseling or case management staff to accommodate more Proposition
36 clients) and type of program, residential or outpatient.
Residential programs were less likely to have created a separate
treatment track just for the Proposition 36 clients (% 2(1) = 3.066, p = .07).
Residential programs were also significantly less likely to change
the hours that groups or counseling sessions met to accommodate
Proposition 36 clients (y2(l) = 9.04, p = .0026) and were less likely to have
increased the caseloads of counseling or case m anagem ent staff to
accommodate additional Proposition 36 clients (x2(l) = 3.33, p = .06).
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Outpatient programs were significantly more likely to have
established a separate treatment track for the Proposition 36 clients (% 2(1)
= 7.24, p = .0071.
Outpatient programs were also significantly more likely to have
changed the hours that groups or counseling sessions meet to
accommodate Proposition 36 clients (x2(l) = 13.89, p = .0002. They were
also more likely to have changed the length of their standard treatment
modality to conform to Proposition 36 standards (x2(l) = 2.97, p = .08).
These programs were also more likely to have increased the caseloads of
counseling or case management staff to accommodate more Proposition
36 clients (x2(l) = 3.50, p = .06).
Hypothesis 2 asserted that there was no association between the
type of provider (outpatient or residential) and resistance activities.
Correlation and chi-square analysis was used to test this hypothesis.
Completing an additional Addiction Severity Index (ASI) or other
psychological-social evaluation instrument on clients referred to the
programs by the CASCs was positively associated with being an
outpatient provider and negatively associated with being a residential
provider, but neither of these associations was statistically significant.
Hypothesis 3 tested the association between the programs' overall
experience of Proposition 36 and the compliance and resistance
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activities. Correlation analysis and linear regression analysis was used to
test the hypothesis. The correlations between the compliance and
resistance variables and the overall experience variable can be found in
Table 14 below.
Table 14. Correlation Matrix—Compliance and Resistance Activities
Variable 1 2 3 4 5 6 7 8
1 Hired NS .29*** NS .38**** NS -.2 1 * -.24*
staff
2 Track - -
4 4 **** NS
.28*** NS NS NS
3 Hours
3 9 ****
NS .25** NS NS
4 Space — .25** NS NS NS
5 Length NS NS NS
6 Caseload - - NS NS
7 Add'l ASI - - .2 2 *
8 Overall —
*p<.10, **p<.05, ***p<.01, ****p<.001
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A multivariate linear regression model was fit to the data using the
outcome variable "How would you rate your overall experience with
Proposition 36 on a scale of one to ten, with one being the worst possible
experience and ten being the best possible experience." Initial model
building began with those variables that were significantly associated
with the dependent variable based on correlation analysis. These
variables included responses to seven questions/statements: doing an
additional psychological/social evaluation in addition to the ASI; having
a high turnover rate among our counseling staff; the importance of ex
addicts in service delivery; having invested a lot of resources in staff
training; sharing problems and solutions with other treatment providers;
believing that Proposition 36 treatment intensity is sufficient and realistic;
and hiring new staff. The regression using all seven variables is shown in
Table 15 below.
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Table 15. Preliminary Regression Results Predicting Overall Proposition
36 Experience
Variable B SEB
( 3
Intercept 3.73 1.96* 0
Q33 psych-
social evaluation 0.37 0.56 0.08
Q24 high turnover
counselors -0.16 0.24 -0.08
Q30 importance
of ex-addicts 0.41 0.23 0 .2 1 *
Q21 invested
in training 0.37 0.26 0.18
Q19 share
problems 0.27 0 . 2 2 0.17
Q15 TX intensity
sufficient 0.28 0.19 0.19
H ired staff -1.09 0.51 -0.27**
*p<.10, **p<.05
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As the table shows, many of the variables did not retain their
significance when entered into the multivariate model even though the
model overall was highly significant and accounted for 39 percent of the
variance between the dependent variable (F = 3.88, p = .0024). The next
step was to remove those variables that were not significant multivariately
and find a parsimonious model for the data.
Three variables were included in this parsimonious regression
model, which is provided in the table below. The model was significant (F
= 4.94, p = .044) and accounts for 22.8 percent of the variance in the
outcome variable as shown in Table 16.
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Table 16. Final Regression Model Predicting Overall Experience With
Proposition 36
Variable B SEB
P
Intercept 8.47 1.15 0
Q19 We share problems and
solutions with other providers 0.60 0.196 0.40**
Hired new staff -1.14 0.482 -0.29**
Acquired additional space -0.92 0.521 -0.23*
*p<.10, **p<.05
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Overall experience with Proposition 36 is associated in the
multivariate model with three compliance variables, sharing problems
and solutions with other treatment providers, having hired new staff, and
acquiring additional space. The parameter estimate on the sharing
problems and solutions with other treatment providers variable is
positive, indicating that this is positively associated with the overall
Proposition 36 experience. The sign on the hiring variable's parameter
estimate is negative indicating that having hired new staff is negatively
associated with overall Proposition 36 experience. The sign on the
acquiring additional space variable is also negative, indicating that it, too
is negatively associated with the over Proposition 36 experience.
Hypothesis 4 tested the assertion that perceptions of clients were
associated with overall Proposition 36 experience. Five variables
attempting to capture information on the respondents' perception of
Proposition 36 clients were identified. These five variables were Likert
scale items captured on a scale of 1 to 5 (1= strong disagreement and
5=strong agreement). They are: Q 8 (Proposition 36 clients know they
have 3 tries at recovery when they are admitted to the program); Q9
(Proposition 36 clients do not understand the attendance requirements);
Q12 (Proposition 36 clients are not interested in recovery when they are
first admitted to the program); Q26 (There is no difference between
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Proposition 36 clients and the clients we see on our other contracts); and
Q27 (Proposition 36 clients are more likely to be dually diagnosed than
our other clients).
None of the client perception variables had a statistically significant
association with the overall experience variable. Three of the variables
(Q8 , Q9 and Q12) were positively associated with overall experience,
while Q26 and Q27 were negatively associated with overall experience of
Proposition 36.
Hypothesis 5 tested whether there was an association between the
resistance activities and perceptions of clients. The same five client
perception variables used to test hypothesis 4 were used to test this
hypothesis. The resistance variable was Q33, whether the program
completed an additional ASI or other psychological-social evaluation of
clients in addition to the ASI completed by the CASCs. Correlation
analysis was used to test the associations between variables.
With the exception of Q26 (there are no differences between
Proposition 36 clients and the clients on our other contracts) all of the
correlations between the resistance activity and the client perception
variables w ere positive. O nly Q26 w as n egatively associated w ith
completing an additional ASI on clients. None of the associations between
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the resistance variable and the client perception variables were statistically
significant.
Hypothesis 6 tested whether financial concerns were associated
with any of the compliance and resistance activities. The five compliance
activities (hiring new staff, creating a separate treatment track for
Proposition 36 clients, changing the hours that sessions met, changing the
length of treatment, increasing the caseloads of case managers, and
obtaining additional space) were used in the correlation analysis. The
resistance variable of completing an additional ASI on clients was also
used in the analysis. The financial variables identified for this analysis
were Q ll (reimbursement levels on Proposition 36 cover the costs of
Proposition 36 clients), Q20 (our invoices are seldom paid on time by the
County), Q22 (our agency has used Proposition 36 funding to replace
other funding streams), and Q23 (there are many costs associated with
Proposition 36 not covered by the funding).
The correlations between the compliance and resistance activities
and the financial variables are displayed in Table 17.
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Table 17. Correlation Matrix of Compliance and Resistance Activities and
Funding Concerns Variables
Variable
Q ll
Q20 Q22 Q23
Hired Staff .07 (NS) -.17 (NS) -.18 (NS) -.24**
Track .04 (NS) -.09 (NS) -.2 2 * .03 (NS)
Hours .11 (NS) - . 2 2 (NS) -.11 (NS) .03 (NS)
Space .16 (NS) -.21 (NS) -.05 (NS) -.01 (NS)
Length .04 (NS) -.05 (NS) -.14 (NS) -.13 (NS)
Caseload .2 1 * -.15 (NS) -.20 (NS) - . 2 1 (NS)
*p<.10, **p<.05, ***p<.01
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Only one of the financial variables, Q23 (there are many costs
associated with Proposition 36 not covered by our funding) was
significantly associated with any of the compliance or resistance activities.
Q23 was negatively associated with hiring staff, and this association was
significant at p = .05.
Hypothesis 7 asserted that overall experience with Proposition 36
was associated with experience with the Proposition 36 program, defined
as the year in which the program received its first client. There are only
three years in which a program could have received its first client, 2001,
2002, and 2003. Correlation analysis was used to test this hypothesis.
The correlation between the overall experience variable and the
year variable was negatively association and non significant (r = -.06, p =
NS). An investigation of the mean scores for each of the three years
revealed that for 2001 the overall experience was rated at M = 7.74; for
2002 overall experience was M = 6.63; and for 2003 overall experience was
M = 8.3.
Hypothesis 8 tested whether compliance and resistance variables
were associated with program values. The six compliance variables used
in the other hypothesis testing w ere used in this analysis as w as the
resistance variable of completing an additional ASI on clients. The
program value questions identified were Q15 (Proposition 36 treatment
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intensity is sufficient and realistic); Q17 (It is impossible to run a drug
treatment program without urine testing); Q29 (How important are
masters degrees or Ph.D. for service delivery); Q 30 (How important are
ex-addicts for service delivery); and Q31 (How important is complete
sobriety for clients). Correlations are presented in Table 17.
Table 18. Correlation Matrix of Compliance and Resistance Activities and
Program Values Variables
Variable Q15 Q17 Q29 Q30 Q31
Hired Staff .02 -.03 .02 .01 .06
Track .03 - .06 -.11 .02 .13
Hours -.13 -.30*** -.14 -.06 -.18
Space -.13 -.12 .01 .11 -.002
Length .12 -.04 -.11 .08 -.01
Caseload .01 .05 -.22 -.09 -.13
Add'l ASI .08 .10 -.10 .19 -.13
*p<.10, **p<.05, ***p<.01
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None of the program values variables were significantly correlated
with compliance or resistance activities.
Overview of the Results
Hypothesis 1 was supported by the data: HI: Differences will be
found between outpatient and residential programs with respect to
Proposition 36 compliance activities.
There were significant differences between the types of programs
(outpatient compared to residential) with respect to compliance activities
undertaken by the programs. Chi square analysis revealed that outpatient
programs were more likely to change the hours that groups and
counseling sessions met; there was also a trend toward outpatient
programs being more likely to change the length of the program's
standard treatment modality to conform to Proposition 36 standards and
more likely to increase the caseloads of counseling and case management
staff. The only compliance activity for which there was no difference
between outpatient and residential providers was on whether they hired
any new staff.
Outpatient and residential treatment providers operate in very
different environm ents w ith respect to clients. R esidential program s have
clients on the premises 24 hours per day, 7 days per week. Living in close
proximity to clients restricts the types of changes they need to make in
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order to accommodate clients' needs. Outpatient providers, on the other
had, have a vested interest in accommodating different types of clients
who may need counseling activities scheduled around their work or
family commitments.
Hypothesis 2 was also supported by the data: H2 There will be no
association between type of program (outpatient compared to residential)
with respect to Proposition 36 resistance activities. Chi square analysis
revealed no differences between outpatient and residential programs with
respect to whether they were more or less likely to complete an additional
psychological/social evaluation in addition to the ASI done by the county
assessment centers. This finding is consistent with the hypothesis that
both types of programs have a vested interest in controlling, to some
extent, the types of clients that they receive into their programs. Both
types of programs have reasons to identify "problem" clients early in the
assessment and intake process.
Hypothesis 3, that overall experience of Proposition 36 was
associated with compliance and resistance activities was partially
supported. Compliance activities were shown to be associated with
Proposition 36 experience, but the resistance activities w ere not. The
positive sign on the parameter estimate for the compliance variable of
sharing solutions with other treatment providers indicates that
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networking with the other Proposition 36 providers was positively
associated with a higher overall experience score. This is consistent with
the literature on inter-organizational networking; for those providers
participating in the activities arranged by the counties, such as roundtable
discussions and SPA meeting, there was a benefit.
The negative signs on the parameter estimates for the other two
compliance variables included in the final multivariate model, hiring new
staff and acquiring additional space, indicates that they were negatively
associated with overall Proposition 36 experience. These activities place
stress on the organization. Hiring staff requires that time be spent on
training them; acquiring additional space requires negotiation time for the
acquisition, and may require remodeling or moving of offices. Again,
these activities place stress on the organization. Both activities are
associated with accommodating additional clientele, which also places
stress on the organization. While they may ultimately be good for the
organization in as much as they are capacity expansion activities, in the
short term they require that resources be taken from service delivery
activities.
H ypothesis 4 w as not supported b y the data. This hypothesis: H 4
Staff perceptions of clients will be associated with the programs' overall
experience with Proposition 36 revealed that none of the questions
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associated with staff perceptions of clients were associated with the
overall experience the program had with Proposition 36 as indicated by a
scale of from 1 "worst experience" to 10 "best possible experience."
Variables that were considered to be staff perception variables included
Q1 (I am confident that the county assessment center is sending Prop 36
clients who are appropriate for out program); Q8 (Most Prop 36 clients
know that they have three tries at recovery when they first come into the
program); Q9 (Most Prop 36 clients do not understand the requirements
for attendance at 12-step meetings and counseling sessions when they are
admitted to the program); Q ll (Prop 36 clients are not interested in
recovery when they are first admitted to the program); and Q14 (The
intensity of treatment clients receive under Prop 36 is sufficient and
realistic). All of the correlations show non-significant associations
between these variables.
The same variables for staff perceptions (Ql, Q8, Q9, Q ll, Q14)
were used to test hypothesis 5: Perceptions of Proposition 36 clients is
associated with resistance activities. One resistance activity was used in
this analysis, Q33, completing an additional psych/social evaluation in
addition to the ASI done by the county assessm ent centers. This
resistance activity was not associated with any of the staff perception
variables.
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Hypothesis 6 tested whether compliance and resistance activities
were associated with Proposition 36 financial concerns. Financial
concerns were captured by Q20 (Our invoices are seldom paid on time by
the county), Q22 (we have used Prop 36 funding to replace other funding
streams) and Q23 (there are many costs that are not covered by Prop 36
funding). The compliance activities consisted of the ones used throughout
this study as compliance activities (hiring staff, creating a separate
treatment track, changing hours, acquiring space, changing the length of
the treatment program, and increasing the caseloads of staff). There was
some support found for this hypothesis, as two of the financial variables
were significantly associated with compliance activities. Hiring staff was
significantly negatively associated with many costs not being covered by
Proposition 36 funding (r = -.24, p = .05) and changing the hours that
groups meet showed a trend toward being significantly associated with
using Proposition 36 funding to replace other funding streams (r=-.22, p
=.07). One explanation for this may be that resistance activities are
tempered by awareness of the resources attached to participation in
Proposition 36 activities. Programs probably will not engage in overt
resistance to activities that are part of a contractual relationship betw een
them and the counties. Such overt resistance could result in sanctions, up
to and including severance of the contract for noncompliance. Unless a
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drug treatment provider had come to a decision that it could not conduct
Proposition 36 activities within the framework of its existing program and
was ready to terminate the contract, it would not overtly resist most of the
conditions for receiving Proposition 36 funding. Resistance for most
programs would be mediated by funding concerns.
Hypothesis 7 tested whether the length of the program 's experience
with Proposition 36 as measured by the year in which they received their
first Proposition 36 client was associated with the programs' overall rating
of their Proposition 36 experience. The results from the multivariate
regression analysis indicate that three compliance activities were
associated with overall experience, one was positively associated and two
were negatively associated. The three years in which it was possible to
have received the first Proposition 36 client (2001,2002, and 2003) were
dummy coded for inclusion in the regression analysis, but only 2002
(dummy coded as year2) was significant at a level less than p= .15. 2002
was significant at p = .11 when included in the final multivariate
regression model, but because it did not meet a significance level of p -
.10, it was not retained in the final parsimonious model.
H ypothesis 8 tested associations betw een program valu es and
compliance and resistance activities. Increasing the caseloads of staff
showed a trend towards being significantly associated with the
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importance of professionals for service delivery (r = -.22, p = .07). From a
program philosophy point of view, it is possible that programs that use
professionally educated persons for service delivery would be less likely
to increase caseloads for staff because they would be aware of the possible
negative consequences of increased caseloads for client outcomes. All
other associations between compliance variables and program
demographics were not significant.
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Chapter Six
Conclusions and Discussion
Organizational theorists have long been concerned about the
impact of environmental factors on organizations. Organizations must
manage their task environments, and they employ many different
strategies to this end. A catalog of strategies employed by organizations
to mitigate the impact of environmental factors could be compiled: such a
catalog would include buffering and bridging strategies (Scott, 1998); and
adaption and selection strategies (Aldrige, 1999). Buffering or defensive
strategies against environmental factors have been identified to include
such things as acquiescence, compromise, avoidance, defiance, and
manipulation (Oliver, 1991). Compliance and resistance activities are a
form of defensive strategy that occurs in response to structural
constraints, and these defensive strategies can be employed by
organizations within an organizational field, or by individuals operating
at a micro level within an organization. Whether at a micro (individual)
or macro (organizational) level, compliance and resistance activities
provide an entity with behavioral ways of coping with uncertainty
associated with environmental factors (Wicks, 1998). The purpose of this
research was to examine the responses of drug treatment programs to
implementation of Proposition 36. Proposition 36 is the large-scale
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implementation of drug treatment for nonviolent drug offenders rather
than jail or prison. The implementation of Proposition 36 deployed
resources into the environment of drug treatment programs. These
resources took two main forms: funding for drug treatment for a large
number of individuals, and the individuals themselves. This research
looked at what the drug treatment programs that accepted funding for
Proposition 36 from the counties in California did to adjust to this
environmental change. In Phase I of the research, compliance and
resistance activities were identified as some of the behavioral strategies
employed by drug treatment programs as they adapted to the
requirements of Proposition 36. Compliance and resistance activities were
further explored in Phase II of this research with respect to the impact that
these types of activities had on several outcomes, including the program's
overall experience of Proposition 36 implementation.
All of the drug treatment programs involved in this research had
practical, day-to-day experience working with drug-addicted or alcohol
dependent clients prior to the implementation of Proposition 36. In this
respect, none of the participating programs was getting into a new area of
activity w ith the im plem entation o f Proposition 36. Each o f the key
informants interviewed in the two phases of the research also were, for
the most part, individuals experienced in working with the population
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targeted by Proposition 36. Yet the majority of individuals interviewed as
part of this research acknowledged some major impact of Proposition 36
on the way in which the provided services and did business.
One of the biggest impacts of Proposition 36 was the initial lack of
funding for urine testing; for the proponents of Proposition 36 when it
was put before the voting public, the emphasis was on keeping
individuals who needed help for drug addiction out of prison or jail. The
emphasis of the campaign to promote Proposition 36 with the voters was
on recovery, not control, as represented by prison or jail. Funding for
urine testing was specifically identified in the original legislation as being
a prohibited use of Proposition 36 funds. Urine testing was seen as part of
the larger criminal justice infrastructure that sought to control and punish
individuals who needed help.
For the drug treatment community, lack of funding for urine
testing was hard to fathom. They saw urine testing as a treatment tool.
The prohibition on the use of Proposition 36 funds for urine testing
provided the first of many opportunities for drug treatment providers to
comply or resist an aspect of Proposition 36 with which they did not
agree. In 2002, G overnor Gray D avis signed legislation p roviding for
urine testing funds for Proposition 36 clients and providers. This is a
good indication of the support drug treatment providers and law
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enforcement officials were able to garner, not simply to resist, but to
change, aspects of Proposition 36. If Oliver (1991) is correct, then the
activism that led to change in availability of funding for urine testing also
laid the groundwork for momentum for drug treatment providers to
actively engage in activities to comply or resist Proposition 36.
Oliver's (1991) typology of responses to environmental factors
ranges from acquiese and compromise to avoidance, defiance and
manipulation. By her definition, compliance is a form of acquiescence, but
it is more active than what she defines as habit or imitation. Compliance
is defined as "conscious obedience to or incorporation of values, norms, or
institutional requirements" (p. 152). The definition of compliance
activities used in this research is very similar to this one. Compliance
activities included changing the length of the program 's standard
treatment modality to conform to Proposition 36 requirements, which is a
clear example of "conscious obedience" to Proposition 36 requirements.
Resistance activities in Oliver's typology are formed by a
continuum that starts with dismissal as the least active form of resistance
to environmental factors, followed by challenge and attack. The resistance
activity identified in this research, reassessing clients w h o had already
been assessed for their level of addiction by the county or one of its
assessment centers, would be considered dismissal by Oliver.
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Dismissing, or ignoring institutional rules and values, is a strategic
option that organizations are more likely to exercise when the
potential for external enforcement of institutional rules is perceived
to be low or when internal objectives diverge or conflict very
dramatically with institutional values or requirements (p. 156).
This is exactly the case with respect to drug treatment providers
exercising their ability to reject an inappropriate client on the basis of the
assessment of that client done by the county.
Two of the key components of Proposition 36 are assessment of
each offender's level of addiction by using a standardized instrument, the
Addiction Severity Index (ASI), and placement in a drug treatment
program for treatment services at a level that matches the client's assessed
level of addiction. These two components, assessment and placement,
directly impact the drug treatment providers who are contracted with the
counties to provide treatment services under Proposition 36.
The Addiction Severity Index is a standardized instrument that has
been used in a wide variety of alcohol and drug treatment settings. It was
originally developed for use in the Veteran's Administration for the
assessment of addicted veterans. Since its inception, it has been widely
used. However, despite its wide usage, the ASI was never intended to be
used in a criminal justice setting where drug treatment was essentially a
"sentence" imposed in place of jail or prison time.
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Psychologists recognize a concept involving conditions of testing.
Conditions of testing are the circumstances under which an instrument is
administered. There are optimal conditions of testing; for some
instruments, there may be prescribed conditions that must be met for the
test results to be considered valid. In the case of the use of the ASI for
assessment of Proposition 36 designation to one of three levels of
addiction, the prescribed "optimal" conditions of testing may be violated.
The ASI was developed and validated with clients from the
Veteran's Administration. In that setting, eligibility for addiction
treatment and services is determined by veteran status. In that situation,
there is never any doubt that an individual will receive services as long as
the general criterion of being a veteran of the United States armed services
is met. That setting is not the same as a criminal justice setting, where an
individual may be doing whatever they need to do to either get out of the
system altogether, or get out of the system by the quickest possible route.
Therefore, the ASI assessments obtained by the assessment centers under
Proposition 36 may be very rough assessments of the actual level of
addiction. The conditions of testing under which the ASI is administered
under the Proposition 36 fram ew ork m ay violate the optim al conditions of
testing. This may be one explanation for the treatment programs'
insistence in the Phase I interviews that the ASI is unreliable for their
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purposes. When the treatment programs administer the ASI again after
the Proposition 36 client has been in the treatment program for a period of
time (many providers cited 30 days as the timeframe they use), that
administration may approximate the necessary conditions of testing better
than the circumstances under which the first ASI was done.
Anastasi (1982) notes the following with respect to testing and
assessment of special populations:
Special motivational problems may be encountered in testing
emotionally disturbed persons, prisoners, or juvenile delinquents.
Especially when examined in an institutional setting, such persons
are likely to manifest a number of unfavorable attitudes, such as
suspicion, insecurity, fear, or cynical indifference. Special
conditions in their past experiences are also likely to influence their
performance adversely ... the experienced examiner makes special
efforts to establish rapport under these conditions, (p. 35)
The original creators of the ASI also noted that the ASI was not
recommended for certain drug-using criminal-justice-involved
populations. The creators of the ASI stated in an early reliability and
validity study, "A second subgroup of substance abusers with which we
have had little success is a small but significant group of younger,
generally drug addicted, patients often having a history of criminal
involvement. Many of these patients deliberately misrepresent their
objective answers and their subjective patient ratings" (p. 422) (McLellan,
1980).
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Placement is the second key component of the Proposition 36
framework. Once a client has been assessed, he is placed in a drug
treatment program that is certified by the county to be able to provide the
specifics of treatment for his assessed level of addiction. There are three
levels: Level I, Level II, and Level III. This concept of "matching" a client
to a program is not a new one. However, Proposition 36 is a very large-
scale attempt to match clients to treatment within a criminal justice
framework. Most previous work on treatment matching has been done
with populations of clients who were not criminal justice involved.
Another aspect of treatment matching involves the "match" of the
client to the treatment that best fits his needs. In many treatment-
matching studies, the "match" of the treatment was on a more refined
scale than found in the three levels used in Proposition 36. The counties
certified providers as being providers of Level I, Level II, or Level III
services. These are very broad designations that differentiate between
outpatient and residential treatment at the crudest levels. Within those
two treatment modalities (outpatient and residential) Proposition 36
makes a further distinction of treatment based on the length of time the
client w ill spend in treatm ent, w hich varies from 90 to 180 days w ithin
each modality. But within the residential/outpatient dichotomy, and the
length of stay continuum there is not much variation in the other
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components of treatment. Group and individual counseling sessions are
mandated for all three levels, as is attendance at 12-step meetings.
Treatment matching traditionally goes beyond such superficial
designations of treatment modality and length of time. Additional criteria
used in matching include the American Society of Addiction Medicine
(ASAM) criteria, which include demographic and cultural characteristics
and needs of the client, as well as client preferences. Other matching
criteria may include placement in a program that is either "high" structure
or "low" structure, an approach that has been reported to have good
outcomes for clients (Nielson, Nielsen, & Wraae, 1998). Finally, some
matching criteria go even further, using matching variables that include
typology and severity of drug use based on age of onset, severity of
intoxication, withdrawal, quantity, recency and frequency of substance
use; intrapersonal characteristics including psychiatric diagnosis,
cognitive functioning, self-efficacy, and stage of change or readiness for
treatment, and interpersonal function such as social stability (Gastfriend &
McClellan, 1997).
One aspect of drug treatment providers' resistance activities under
Proposition 36 m ay be related to the crudeness of the treatm ent m atching
criteria used in Proposition 36. The assessment centers did not have an in-
depth understanding of the specifics of the treatment being provided
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within each treatment program; the programs themselves had more
knowledge of what their treatment environment was like than the
assessment centers had. The treatment providers were much better
positioned to know if a client would fit into their treatment program than
the assessment centers were. Consequently, drug treatment programs
engaged in resistance activities that included sending clients back to the
assessment centers for reassessment, which usually meant placement in a
different drug treatment program. In essence, the drug treatment
programs were indicating that the "match" was not a good one from their
perspective and that the client needed to be "matched" to a different drug
treatment provider.
The phenomenon of clients being sent back to the assessment
centers was noted in the 2002-2003 Annual Report put out by the County
of Los Angeles Department of Health Services on Proposition 36 (2004).
This report notes that the assessments centers assessed a total of 8,048 new
participants who reported as required. However, the report says that the
assessment centers actually had a total of 26,869 contacts "to provide such
services as assessments, evaluations, re-evaluations, referrals and re
referrals" (p. 11). A ccording to the report, "m any participants returned to
the CASCs approximately 2-3 times during their period of treatment" (p.
11).
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Three reasons are given in the report for this high number of contacts with
clients:
The reasons for these contacts included: assessed for referral to
appropriate treatment programs; transferred to outpatient
programs following successful completion of residential treatment;
or referred to new programs following unsatisfactory termination
by previous treatment providers, court-ordered referrals, and
service changes (p. 11).
This third reason is directly addressed in this research and provides
outside verification that the experience of the providers who were
interviewed as part of this research was part of the countywide
experience.
A frequently mentioned criterion for treatment matching within the
drug treatment literature is patient preference. While the research is
inconsistent as to whether complying with a patient preference in
treatment placement leads to better overall treatment outcomes, it is clear
that client preference is not a criterion employed with criminal justice
involved clients. By its nature as a criminal justice-linked treatment
program, Proposition 36 does not use client preferences when assigning a
Proposition 36 client to treatment.
Overall, it is not surprising that the drug treatment programs
engaged in activities to manage, if not control, the types of clients they
were receiving under Proposition 36. Given that one component of the
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matching of the clients to treatment providers was based primarily on an
ASI administered to clients under suboptimal conditions of testing, it is
not surprising that both the assessments and the matching that resulted
from the assessments were fraught with problems for the providers.
Other reasons for matching may have involved administrative
discretion on the part of the assessment centers that is not easily
quantified. If a client were sent to a program because that was the only
slot available that day, it may not have been a good match for either the
client or the treatment program. Treatment providers may have been
sending clients back for reassessment as a reaction to such discretionary
placements. Programs may have viewed such a placement as a clinical
mismatch, when in fact it was simply the only treatment slot available.
Whatever the underlying reason, the treatment programs had a need to
control the types of clients being sent to them by the assessment centers.
Compliance and resistance activities provide a framework for discussing
this behavior on the part of the treatment programs.
Directions for Future Research
One question that can be asked regarding Proposition 36 is whether
for those clients w h o w ere not sent back for reassessm ent, if the "match"
of the client to the treatment program resulted in a positive outcome for
the client. Currently, the state of California has contracted with the
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University of California Los Angeles Integrated Substance Abuse
Programs (ISAP) to conduct an outcome evaluation of Proposition 36
statewide. The results of that evaluation may address this question of
how effective implementation of Proposition 36 was at assessing, then
matching, clients appropriately. Outcome results for those clients
completing treatment in 2002 are expected in late 2004.
One area of research would be to distinguish and catalog other
non-clinical reasons for "matching" clients within the Proposition 36
framework. Clients may have been sent to programs, not because of the
ASI assessment, but because that was the only treatment program that
had a vacancy available at the time the client was being placed. This is
alluded to in some of the interviews from Phase I of this research. Other
administrative, non-clinical reasons for client placement could include
taking into account where the client lives and placing him in a program
close to home (as opposed to one that meets his clinical needs), or placing
him in a modality because it is preferred by the assessment center rather
than one clinically suited to the client (e.g., there is some aversion within
criminal justice programs to methadone maintenance). This could help
clarify the types of "judgm ent calls" being m ade by the assessm ent
centers, and more explicitly identify those areas or types of clients with
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which they exercise administrative discretion rather than clinical
assessment.
Another area for future research involves the question of whether it
is possible to tell the difference between Proposition 36 clients and non-
Proposition 36 clients from an examination of their drug treatment
histories. Throughout the interviews, drug treatment providers showed a
prejudice towards the longer treatment stays and a preference for
residential treatment over outpatient treatment. It is an empirical
question as to whether Proposition 36 clients are really different from
other drug treatment clients, or not. One argument is that the drug
treatment providers prefer the longer residential treatment stays over the
shorter outpatient modalities because it is their business to want to see
individuals in longer, more expensive treatment modalities. It is also
consistent with addiction philosophy that individuals enter drug
treatment in denial, and need the additional time and treatment resources
and services to work their way through to an understanding of their
addiction problem.
However, previous research lends some credibility to the notion
that there m ay be no difference b etw een the tw o types of clients, i.e., those
referred by Proposition 36 and those seeking treatment on their own.
Research on addiction careers indicates that there is a progression from
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casual drug use to addiction, and after addiction a progression (or
downward spiral) through job loss, engagement in criminal activities
(such as robbery or theft to fund the drug habit) that go undetected,
followed by involvement with the criminal justice system (as illegal
activities accumulate and the individual is eventually caught), and jail or
prison. There may be some truth to the notion that the person picked up
by Proposition 36 has reached a higher stage in his addiction career as
evidenced by the criminal charges that brought them into the Proposition
36 program. Charting or comparing addict careers could show whether
there is a difference between Proposition 36 clients and other clients and
help determine whether drug treatment providers are actually exercising
sound clinical judgment when they say there is no difference, or simply
articulating the prejudices of the field.
Finally, investigating the impact of the shared data system on drug
treatment providers would also be an interesting area of study. Many of
the drug treatment providers did not have computers at all prior to
Proposition 36; for others, computers were available only to certain key
individuals within the program, i.e., the Executive Director or the
bookkeeper. D rug treatm ent counselors and intake staff are not generally
knowledgeable about web-based data collection systems and most of the
data systems implemented for Proposition 36 were new and developed
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specifically to track clients between the courts, probation, and treatment.
In Los Angeles and Orange counties, the contracts specifically provided
for the set-up of a Proposition 36 "office" within each participating
treatment program, and funding for the office included funds for the
purchase of at least one desktop computer.
Much of the early training done for treatment providers by the
counties was on how to access, use, and update client records in the
shared data systems. Organizational researchers have acknowledged the
impact that technology and technology upgrades can have on
organizations. Charting the impact of the deployment of the shared data
systems on the treatment providers could provide an interesting study of
the impact of technology on what was a fairly low technology human
services delivery system, i.e., community-based drug treatment providers.
Limitations of the Research
There are several limitations of this study that must be
acknowledged. First, data collection for both Phase I and Phase II
occurred over several months time in each case. Phase I data collection
started with the piloting of the semi-structured interview questionnaire in
Septem ber 2002 and continued through February 2003. Phase II data
collection started around May 2003 and continued through November
2003. During this time, several things occurred in the environment of
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Southern California that could have influenced how Proposition 36
evolved in practice throughout the participating drug treatment
programs. For example, the state of California went from having a budget
surplus to having a $35 billion deficit. This deficit affected the counties of
Southern California disproportionately, and this, in turn, affected drug
treatment providers in different ways in different counties. During the
telephone interviews, it was not unusual to be told that a drug treatment
program had initially hired new staff to work on Proposition 36, but that
they had recently been forced to lay those same new hires off due to
budget considerations.
In addition, the length of care mandated under Proposition 36 was
changed in some counties in response to the changed budget climate. In
Los Angeles County, for example, Proposition 36 clients initially were
allowed "three strikes" or attempts to succeed under Proposition 36. That
is, if placed in treatment for the first time, and they failed at treatment or
completed treatment but were rearrested for drug related charges and
placed back into treatment under Proposition 36, the clock started over on
their length of time in treatment. However, in the changed budget
clim ate, this w as no longer the case. Individuals w ho w en t into treatm ent
once under Proposition 36 had that initial time credited to them. If they
failed to complete treatment and had to start over, or completed
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treatment, but were rearrested, they were not allowed to begin over with a
full 180 days of treatment that they could use. They were credited for the
amount of previous time in treatment, and that was deducted from their
treatment balance, as it were. These changes in procedures undoubtedly
had an impact on the treatment providers' perceptions of both Proposition
36 and the clients they were receiving for care, but no attempt to follow
these ecological changes in the environment was made in this research.
In Orange County, in May of 2003, the County ran out of funds for
residential treatment until the new fiscal year began on July 1s t. This also
had an impact on drug treatment providers in that county and may have
affected both the total numbers of clients reported to be in residential
treatment, and the total numbers in outpatient treatment. The County
sent eligible Proposition 36 offenders, during that time period, into
outpatient care until after the fiscal year began, at which time they were
transferred into residential treatment. Again, no effort to track the impact
of this ecological change was attempted.
One of the main outcome variables, the question about overall
experience with Proposition 36 may not have captured the "true"
experience of the program or respondent with Proposition 36. M any of
the telephone interviews were longer than the average 12-15 minutes
because many respondents wanted to answer the questions in more
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detail than originally called for. The interviewer did not attempt to cut
these conversations short, but made notes as the respondent commented
on various aspects of Proposition 36. In these interviews, it was not
unusual for the respondent to voice many complaints, either about how
the county was handling some aspect of Proposition 36, or about some
problem the program was having with clients. However, often after these
lengthy interviews, the respondent would rate their overall experience
with Proposition 36 very high. It is possible that the rating of experience
was not really an indication of overall experience with Proposition 36, but
an indication of how hopeful the respondent was either that ultimately
Proposition 36 would be beneficial to clients or that problems would be
worked out.
Other respondents refused to answer the overall experience
question. Some of the reasons given for this were "it is still a work in
progress" or "it is too early to tell." Because of this, there was much
missing data on this question, which in turn could affect the validity of the
results. Other respondents indicated that this researcher should "ask the
County" if this researcher wanted an answer to that question, again,
refusing to answ er concerning their experience overall w ith Proposition
36. Finally, some respondents wanted to know which aspect of
Proposition 36 this researcher wanted them to indicate their experience
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with. In those cases, the respondents indicated that their experience with
the procedures established by the County was very different from their
experience in working directly with Proposition 36 clients. There was no
pattern in these responses, as some respondents who wanted the question
to be more specific had many negative things to say about county
requirements, but rated their experience with Proposition 36 clients very
highly; others rated their experience with the County very high as far as
support, technical assistance, and payment of invoices, but were less than
satisfied with their experience in working directly with the clients. The
question on overall experience was not changed to accommodate these
various aspects of Proposition 36 with which the program could be either
more or less satisfied with, so in some cases, it is not clear which
experience underlies the actual response to the question.
Some respondents, despite assurances that the interview would not
be turned over to the County, were hesitant to say anything bad about
their experience and asked "Are you sure that none of this will get back to
the County?" Fears that responses would not be kept confidential could
have influenced some respondents to answer some of the questions less
candidly than they otherw ise w ou ld have.
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Alternative Explanations and Theoretical Approaches
The large scale implementation of Proposition 36, with its emphasis
in most counties on attendance at various meetings, including district
meetings, Service Provision Area (SPA) meetings (Los Angeles County),
and roundtable meetings might lend itself to analysis based upon inter
organizational coordination and network analysis (Alexander, 1995).
Alexander (1995) discusses both informal and hierarchical coordination
between organizations; both would be applicable to Proposition 36, where
some of the meetings were set up by the counties (at the top of the
hierarchy) and some of the exchanges between treatment providers could
be characterized as informal networking efforts. Identifying which
programs participated and which did not, which served in the capacity of
coordinator, and which acted as liaison boundary spanners, could provide
insights into how changes to the operationalization of Proposition 36
activities occurred and who the primary catalysts were.
Network analysis could also provide some insight into the
development of new relationships between types of organizations that
had not previously had working relationships. For example, several
program s m entioned that they had no previous w orking relationships
with probation or parole, or that they had had slight contact in the past of
a negative nature. Proposition 36 forced these providers to cooperate
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with each other in new ways, to the mutual benefit of each. The
implementation of Proposition 36 required coordination between the
courts, probation, Alcohol and Drug Program Administration, other
County agencies, the California Department of Corrections/Parole,
various sheriffs' offices, the public defender's office, the district attorney's
office, and community-based treatment providers. Within Los Angeles
County, the county Board of Supervisors created the Proposition 36
Implementation Task Force, which is governed by an Executive Steering
Committee. In addition, Los Angeles Alcohol and Drug Programs
established four regional coordinating councils to address issues of local
concern and facilitate communication between community members and
the Executive Steering Committee. Network analysis could begin to help
clarify which relationship evolved, how these relationships and
interactions developed and changed over time, and some of the outcomes,
both positive and negative, of the relationships that developed.
Finally, Ruth Hoogland Dehoog (1990) in her article on
"Competition, Negotiation, or Cooperation: Three Models for Service
Contracting," reviews the various options for contracting available to
governm ent entities and the circum stances under w hich they m ay work
best. Proposition 36 could be classified as contracting under the
competition model in Dehoog's typology, with its specification of
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required services to be offered under Proposition 36, and it "objective
cost- and performance-monitoring procedures" (p. 320). However, there
is also evidence from the interviews performed in Phase I of this research
that Proposition 36 also has aspects of the cooperative model in its
contractual implementation.
Dehoog's description of the use of cooperative contracting in
human service organizations is very similar to the implementation of
Proposition 36. "In one county, private agency representatives met
monthly with county officials to discuss service needs and program
changes" (p. 332). It is possible that a hybrid form of contracting,
combining the best aspects of competitive and cooperative contracting,
could be identified by examining the aspects of each type of contracting as
it was used in Proposition 36 implementation. The large scale on which
Proposition 36 was implemented, and the large numbers of stakeholders
involved in that implementation, highlights the need for contracting with
drug treatment providers that allows for both flexibility in service
delivery, but accountability for the contracted organization. Research on
models of service contracting has been going on since the 1970s, and may
p rovide insights into the current practices of the counties that are
managing Proposition 36.
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Appendices
Phase I Questionnaire - Qualitative Interview
Phase II Questionnaire - Telephone Survey Interview
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Phase I -Semi-Structured Interview Questions
Background Questions
1. Interviewer: How long have you worked in substance abuse treatment?
2. Interviewer: How long have you worked here?
3. Interviewer: What is your highest level of education?
4. Interviewer: What certifications do you have?
5. Interviewer: What is your official job title?
6 . Interviewer: What is the title of the person you report to (your immediate
supervisor)?
I'm interested in learning about how Proposition 36 was implemented in
local drug treatment programs, and your experience during the past year. The
questions I'm going to be asking concern the time period of last summer (July 1,
2001) to the current time.
11. When did you first hear about Proposition 36 within the context of your
job?
12. Is there a particular meeting that you attended in the last year concerning
implementation of Proposition 36 here at_________________ (name the
program) that particularly stands out in your memory?
13. Do you know the day or approximate date that
(name the program) received its first Proposition 36 client?
14. Were there strong advocates either for or against Prop 36 as legislation
within this treatment program?
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15. What is the organizational structure of the administrative staff, the
director, and the counselors who work with Prop 36 clients? Do you have
an organizational chart that I can obtain a copy of? How many staff
currently work in the program? How many of those work with the Prop
36 contract?
16. Have you hired new staff in order to assist with work on the Prop 36
Contract?
17. What role did the County play in providing information concerning
implementation of Proposition 36?
18. What role did the CASC(s) (Central Assessment Centers) play in
providing information concerning implementation?
19. What were some of the characteristics of the Prop 36 implementation at
your treatment program?
20. What decisions had to be made initially?
21. What decisions had to be made about staffing, increasing the level of
staffing, training of staff?
22. What were the reactions of staff and administration to a lack of funding
for urine testing initially?
23. What drugs does the program currently test for? Will this change (did
this change) since the counties have agreed to pick up some of the funding
for urine testing as of July 1 of this year (2002)?
24. Did_____________(name the program) have strong advocates and/or
strong opponents of Prop 36 among its staff members?
25. What were the initial perceptions of the first Prop 36 clients that came to
the program? Do you receive copies of the ASI done by the CASC? Do
you use the ASI in treatment planning? Have you ever had to send a client
back to the CASC to be reassessed?
26. What was their behavior generally in counseling sessions?
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27. Was the perceived level of need of the Prop 36 clients different from
other______________ (program name) clients?
28. What types of new skills did you or other staff members need to acquire
in order to serve the Prop 36 clients? Did the program have previous
experience working with criminal justice involved clients?
29. How did you acquire these new skills?
30. Are there other skills you feel you need in order to work with the Prop 36
clients that you do not currently have?
31. How clear are the treatment standards for Prop 36 clients? What do you
do to ensure that clients understand the expectations? If outpatient
program, how do you keep track of client attendance at 1 2 -step meetings,
group and individual counseling sessions?
32. Are there any financial issues concerning Prop 36 besides the funding
issues surrounding urine testing?
33. Which CASC do you receive clients from? What is your program’s
relationship with its CASC?
34. What are the key components of the relationship?
35. How does communication take place between _____ (program
name) and the CASC? (i.e., telephone, site visits, written memos?)
36. What types of treatment modalities does______________________
(program name) current provide? Does Prop 36 fit with these existing
treatment modalities?
Thank you very much fo r your time.
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Phase II - Telephone Interview Survey
Hello, my name is Grace Reynolds and I am a doctoral candidate at USC's School
of Policy, Planning and Development. For my dissertation research, I am
conducting a telephone interview of drug treatment programs in counties in
Southern California about their experience with Proposition 36 implementation.
The interview takes about 12 minutes and all of your responses will be kept
totally confidential.
Program Name_______________________________________________
Interviewer __________________________________________________
Interview Date /______/_______
Interview Time ______:______ am pm
For Prop 36 clients, does this program provide outpatient services? Yes No
Residential services? Yes No
For Prop 36 clients, does this program provide aftercare services? Yes No
How many total Prop 36 clients does this program have in its outpatient program?
___________ number don’t know does
not apply
How many total Prop 36 clients does this program have in its residential program?
___________ number don’t know does
not apply
How many staff total work in this program?
___________number
Of those, how many staff work with the Prop 36 clients?
___________number
Has the program hired any new staff to work on the Prop 36 contract?
Yes No 0 0 7
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If yes, have you hired counseling staff? Yes No
If yes, have you hired intake staff? Yes No
If yes, have you hired administrative staff? Yes No
Any other job description hired for Prop 36?
____________________________(specify)
What year did this program receive its first Prop 36 client?
2001
2002
2003
Does this program have regularly scheduled staff meetings? Yes No
If yes, how frequently do staff meetings occur?
Daily
Weekly
Monthly
Other_____________________________ (specify)
Has this program done any of the following with respect to the Prop 36 program:
Created a separate treatment track just for Prop 36 clients? Yes No
Changed the hours that groups or counseling sessions
meet to accommodate Prop 36 clients? Yes No
Acquired additional space through rental or purchase to accommodate
More Prop 36 clients? Yes No
Changed the length o f the program’s standard treatment modality
To conform to Prop 36 requirements? Yes No
Increased the caseloads of counseling or case management staff? Yes No
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For the next questions, rate each of the following items on a scale of 1 to 5, with 5
being total agreement with the statement and 1 being total disagreement with the
statement.
1. I am confident that the county assessment center(s) is sending Prop
36 clients who are appropriate for our program.
1 2 3 4 5
Disagree Agree
2. The paperwork required for Prop 36 does not take much time.
1 2 3 4 5
Disagree Agree
3. Our staff have received adequate training on the computer database
the county uses for tracking clients.
1 2 3 4 5
Disagree Agree
4. Our program has felt some pressure from the County to take more
Prop 36 clients than we can really accommodate.
1 2 3 4 5
Disagree Agree
5. We routinely have a problem with ‘no-show’ clients.
1 2 3 4 5
Disagree Agree
6. The majority of our total program slots are now filled by Prop 36
clients.
1 2 3 4 5
Disagree Agree
7. We routinely use the Addiction Severity Index (ASI) in creating
treatment plans for clients.
229
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1 2
Disagree
3 4 5
Agree
8. Most Prop 36 clients know that they have three tries at recovery
when they come into the program.
1 2 3 4 5
Disagree Agree
9. Most Prop 36 clients do not understand the requirements for
attendance at 12-step meetings and counseling sessions when they
are admitted to the program.
1 2 3 4 5
Disagree Agree
Rate each of the following questions on a scale of 1 to 5, with 5 being total
agreement with the statement and 1 being total disagreement with the statement.
11. The reimbursement levels on our Prop 36 contract cover the costs of
maintaining Prop 36 clients.
1 2 3 4 5
Disagree Agree
12. Prop 36 clients are not interested in recovery when they first come into
the program.
1 2 3 4 5
Disagree Agree
13. We have upgraded our computers, or purchased new computers, since
obtaining the Prop 36 contract.
1 2 3 4 5
Disagree Agree
230
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
14. We have not made any changes to our treatment program to accommodate
Prop 36 clients.
1 2 3 4 5
Disagree Agree
15. The intensity of treatment clients receive under Prop 36 is sufficient and
realistic.
1 2 3 4 5
Disagree Agree
16. Our program brings all concerns to the county’s attention.
1 2 3 4 5
Disagree Agree
17. It is impossible to run a drug treatment program without urine testing.
1 2 3 4 5
Disagree Agree
18. Prop 36 clients should not have to pay anything toward their treatment
costs.
1 2 3 4 5
Disagree Agree
19. We routinely share problems and solutions with other treatment providers
concerning Prop 36 issues.
1 2 3 4 5
Disagree Agree
20. Our invoices are seldom paid on time by the County for the Prop 36
contract.
1 2 3 4 5
Disagree Agree
231
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21. We have invested a lot of resources in staff training to manage the Prop
36 contract.
1 2 3 4 5
Disagree Agree
22. Our agency has used Prop 36 funding to replace other funding streams.
1 2 3 4 5
Disagree Agree
23. There are many costs associated with the Prop 36 contract that are not
covered by our County funding.
1 2 3 4 5
Disagree Agree
24. We have a high turnover rate among our counseling staff at this agency.
1 2 3 4 5
Disagree Agree
25. Our agency had little or no experience with criminal justice involved
clients prior to being awarded the Prop 36 contract.
1 2 3 4 5
Disagree Agree
26. There is no difference between the clients we see on our other contracts
and the Prop 36 clients.
1 2 3 4 5
Disagree Agree
27. Prop 36 clients are more likely to be dually diagnosed than our other
client populations.
1 2 3 4 5
Disagree Agree
232
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28. We have never asked the county assessment center(s) to reassess a Prop
36 client.
1 2 3 4 5
Disagree Agree
29. On a scale of one to five, with five being very important and one being
not very important, how important are professionals with master’s degrees
or Ph.D.’s for service delivery in this program?
1 2 3 4 5
Not important Very
important
30. On a scale of one to five, with five being very important and one being
not very important, how important are ex-addicts for service delivery in
this program?
1 2 3 4 5
Not important Very
important
31. On a scale of one to five, with five being very important and one being
not very important, how important is it for clients to maintain sobriety or
complete abstinence from drug use?
1 2 3 4 5
Not important Very
important
32. How many different CASCS does the program receive clients from?
33. Does this program do its own psych/social evaluation of clients, in
addition to the ASI done by the county assessment centers
Yes No
34. How often does your program speak with its County program monitor?
Daily Once per week Several times per month At least quarterly
Less than quarterly 233
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35. What is your gender?
Male
Female
36. What is your primary role at work?
Supervisor
Administrator
Counselor
Assessment
Intake
Other:_______________________
All of the above
37. How many years have you worked in substance abuse treatment?
years
38. How long have you worked at this program?
___________ years
39. On a scale of 1 to 10 with 10 being the best experience possible and 1
being the worst experience possible, how would you rate your program’s
experience with Proposition 36 overall?
1 2 3 4 5 6 7 8 9
10
Worst
Best
Thank you very much for your time. If you have questions about this survey, you
can contact me at greynold@usc.edu or my dissertation advisor, Howard
Greenwald, Ph.D., at his e-mail address: greenwa@usc.edu.
234
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Asset Metadata

Creator Reynolds-Fisher, Grace Lynn (author)

Core Title Drug treatment providers' organizational responses to implementation of California's Proposition 36

School School of Policy, Planning and Development

Degree Doctor of Public Administration

Degree Program Public Administration

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Political Science, public administration

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Greenwald, Howard (committee chair), Clayton, Ross (committee member), Newland, Chester (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-414932

Unique identifier UC11340256

Identifier 3145270.pdf (filename),usctheses-c16-414932 (legacy record id)

Legacy Identifier 3145270.pdf

Dmrecord 414932

Document Type Dissertation

Rights Reynolds-Fisher, Grace Lynn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA