“Being able to speak,” What individuals in jail perceived as helpful about participating in alcohol-related brief interventions

Abstract

Background:

A significant proportion of individuals within the criminal justice system meet criteria for a substance use disorder. Treatments for individuals who are incarcerated with substance use disorders show minimal to no benefit on post-release outcomes, suggesting a need to improve their effectiveness, particularly those that can be delivered in a brief format. The purpose of this study was to describe what individuals in jail with substance use disorders perceived as being helpful about two brief alcohol-focused interventions, which can be used to inform future treatments with this population.

Methods:

Data came from a parent study where fifty-eight individuals in jail with substance use disorders received either a motivational or educational intervention focused on alcohol and other substance use, and then completed a questionnaire assessing what was most and least helpful about the interventions. Qualitative responses were coded using a grounded theory approach.

Results:

Results indicated that participants from both interventions reported that receiving individualized attention and talking one-on-one with someone was helpful, and that the interventions were encouraging and elicited hope. There also were specific components from each intervention that participants said were beneficial, including the opportunity to discuss plans for post-release and to learn about addiction from psychoeducational videos. Participants noted areas for improving future interventions. Suggestions from participants were to offer tangible resources upon release, make session lengths flexible, and reduce assessment burden during research interviews.

Conclusions:

Findings align with established approaches for working with marginalized groups, namely, community-based participatory research methods and shared decision-making models for treatment. This study provided a voice to individuals in jail with substance use disorders, a group often underrepresented in the literature, and may offer an initial look at how to improve treatments for this high-risk population.

Introduction

Approximately half to two-thirds of the 700,000 individuals incarcerated in jails in the United States meet criteria for a substance use disorder.^1–3 Individuals incarcerated in jail tend to have shorter sentences than those incarcerated in prison; typically, jail sentences are one year or less. Of those incarcerated in jails, approximately 25.5% were convicted of a drug offense and almost half of those convicted of non-substance-specific offenses reported using alcohol or drugs at the time of their offense: 47.2% of those with violent offenses and 46.8% of those with property offenses.³ Yet, only 10–20% of individuals in jail received needed substance use treatment while incarcerated.^3–5

Findings from the limited research on treatments for individuals who are incarcerated with substance use disorders are mixed. There are some encouraging outcomes from behavioral treatments with these individuals, such as psychoeducational groups, therapeutic communities, cognitive-behavioral treatment, and contingency management;^6–8 however, there are concerns that these benefits are modest.^9–12 Among individuals in jail who participated in a therapeutic community, those who stayed in the program longer had reduced rates of re-arrest.¹³ While these findings are promising, it may not be feasible for treatments to fit within the short-term duration of jail stays. Others have successfully tested brief interventions with individuals who are incarcerated with substance use disorders, but sample sizes were small, and improvements were similar compared to an active control condition¹⁴ or benefits did not persist from contacting addiction services to attending treatment.¹⁵ These findings suggest that there is a need to improve treatments to be delivered more concisely. Additionally, Prendergast and colleagues¹⁶ found no effect of a screening, brief intervention, and referral to treatment with a large sample of individuals in jail, noting the need to tailor this evidence-based practice to this specific population.

Community-based participatory research is recommended to improve the development, implementation, and dissemination of interventions with diverse and marginalized populations,¹⁷ both of which are defining characteristics of individuals in jail. Among individuals incarcerated in local jails, most (53%) identify as a member of a racial/ethnic minority group.¹⁸ Additionally, treatments for individuals with substance use disorders in jails specifically are understudied. There are barriers to studying this high-needs group related to setting (short-term nature of facilities; available resources), culture within the corrections system,^7,19 and the fact that individuals with criminal justice involvement and substance use disorders more broadly have not been a priority population for treatment resources.²⁰ Community-based participatory research principles can help serve as a bridge between promising treatment approaches designed by researchers and interventions that are informed by community members that can bolster improvements and address disparities.

Given the high prevalence of substance use disorders among individuals incarcerated in jails and the room for improvement in treatments for this population, there is an important opportunity to learn from the experiences and preferences of these individuals regarding existing interventions by directly eliciting their feedback.

We conducted a small pilot study that compared the efficacy of a brief motivational intervention to an educational intervention with individuals in jail with substance use disorders just prior to their release from jail.¹⁴ While both interventions were demonstrated to be feasible in short-term jail settings and there were some encouraging between-group effect sizes (Hedge’s g ranging from 0.294 to 1.198), there were no observable benefits of the motivational intervention. Specifically, from follow-up interviews conducted one to three months post-release, there were no significant between-group differences in targeted outcomes (alcohol or drug use, substance use treatment engagement, or social networks) after controlling for pre-incarceration values. After participants received each intervention, we administered an open-ended survey to qualitatively assess participants’ perceptions of the interventions. The objective of this study was to provide a description of what individuals in jail perceived as being helpful from brief alcohol-related interventions as well as their suggestions for improving sessions. This information can help streamline and develop future interventions for this marginalized population.

Methods

Study Overview

Data for this study came from a randomized clinical trial that compared the efficacy of receiving a brief motivational intervention relative to receiving an educational intervention delivered in the 14 days prior to release from jail.¹⁴ All recruitment, screening, baseline, and intervention procedures took place at a large metropolitan detention center in the Southwest. To recruit individuals, study staff made presentations at four general population units (excluded segregation and medical units at the request of the detention center administrators) where individuals interested in participating could complete a brief questionnaire and provided information for further contact and screening. Eligible individuals participated in an informed consent process that included a short quiz and then signed a consent form. Study staff/interventionists met with each participant in a private room within each unit that offered auditory confidentiality but not visual confidentiality (there were windows to the rest of the unit for safety purposes). All study procedures were approved by an institutional review board at the University of New Mexico.

Participants

Inclusion criteria were: a) having an alcohol or drug-related charge or if their reason for incarceration was due to substance use (e.g., probation violation due to screening positive for drug use), b) sentenced with an upcoming release date within 14 days of the intervention, c) agreement to follow-up after release from jail, and d) moderate to high alcohol involvement in the three months prior to going to jail per the National Institute on Drug Abuse-Modified Alcohol, Smoking, and Substance Involvement Screening Test.²¹ Inclusion criteria aimed to target those with alcohol use disorders who had experienced negative consequences related to their use (e.g., substance-related charges), which may motivate them to change more than those with non-substance-use related charges. Individuals were excluded from participating if they: a) were not proficient in English, b) exhibited gross cognitive impairment per a cutoff of 20 on the Mini Mental Status Exam,²² c) were experiencing active psychotic symptoms per the Structured Clinical Interview for DSM-IV Diagnoses psychotic screening,²³ or d) were actively participating in the methadone maintenance therapy program at the jail.

Interventions Delivered

Three advanced clinical psychology graduate students were trained in both types of brief single session interventions, which were each approximately one hour long, and received bimonthly supervision. At the end of both interventions, participants received a list of substance use treatment referrals in the area (detoxification services, counseling, self-help groups). For participants randomly assigned to receive the motivational intervention, therapists used a motivational interviewing²⁴ approach that primarily targeted the participants’ substance use, and secondarily their social networks or going to substance use treatment, if participants were interested in discussing either of these. Consistent with motivational interviewing, interventionists used open-ended questions, affirmations, reflections, and summaries to explore participants’ substance use and help the participants to resolve ambivalence about continuing their use after release from jail. Sessions began by inviting participants to share their thoughts and experiences with alcohol and drugs using open-ended questions and then became more focused depending on participant preferences. When provided the treatment referral sheet at the end of the intervention, participants were informed of what was on the sheet but participants were not explicitly told to seek these services.

Participants randomly assigned to receive the educational intervention began by watching a 20-minute video on addiction and completed a 10-question quiz while watching the video to focus their attention on the content rather than their own personal experiences. After, interventionists scored and reviewed the quiz responses. If participants began discussing their own alcohol or drug use, or other personal experiences, interventionists redirected them to video content. Next, participants watched a second video on alcohol and drug relapse and repeated procedures from the first video, including completing a quiz and talking about answers with the interventionist. Both videos included research on substance use (e.g., how drugs affect the brain) and had testimonials from individuals in recovery.

Data Collection

For the parent study, recruitment and all interventions were conducted between April 2014 and June 2015. Data for the current study came from fifty-eight individuals who were consented into the original trial.¹⁴ Of note, data from 18 participants ultimately were not included in the analyses for the main trial for various reasons (e.g., changes in study resources precluding participants from being contacted for further follow-up), but all were included in the present study because all participated in a brief intervention focused on their alcohol use and completed the post-intervention questionnaires.¹⁴ The baseline assessment battery took approximately two hours and then participants proceeded to the intervention. Participants completed a questionnaire immediately following their intervention with a verbal prompt that encouraged feedback about the last hour (the intervention) and included these questions: a) What part of the meeting was most helpful?; b) What part of the meeting was least helpful?; and c) Based on your experience, what suggestions would you have for improving your meeting? Each of the three questions was open-ended in an attempt to allow participants to freely generate their own responses. Once completed, participants put their completed questionnaires in a sealed envelope and were thanked for participation. Of note, there were no observed benefits of the interventions from the parent study, therefore, the validity of what participants found “helpful” could not be determined. However, because language from these questionnaires explicitly asked for what most/least “helpful”, results and related discussion from the present study are reported as what participants perceived as being “most” or “least helpful.”

Qualitative Analyses

Data were analyzed using a grounded theory approach by which content themes of text data were analyzed in a systematic classification process.^{25, 26} In a grounded theory approach, the researcher relies upon the participant responses to inform the iterative development of thematic codes, rather than developing codes based on theory or a priori hypotheses. Participant responses were examined by the first two authors (M.D.O. and M.K.) independently to generate a list of potential thematic codes. Subsequently, all authors discussed the potential codes for the data until consensus was reached. The first two authors then coded all participant responses with the revised codes, compared results, and discussed discrepancies in coding. These authors then re-coded the responses based on their discussion, at which point adequate consistency was attained for all question items (>80%).²⁷ Remaining discrepant responses were discussed by the two authors until a final consensus was reached. Lastly, the third author (K.H.) examined the final results to provide additional consensus upon the ascribed codes. Codes were then collapsed across questions and by overarching themes, and were reviewed with all authors to finalize themes and identify prototypic responses for each.

Results

Among the 58 participants, 33 received the brief motivational intervention (56.9%) and 25 the educational condition (43.1%). Participants were predominately male (n=56, 96.6%) and identified as an ethnic minority (n=48, 82.8%), and were an average age of 34.1 years (SD=9.5). In their lifetimes, participants reported an average of 3.4 (SD=4.9) and 2.7 (SD=3.6) alcohol and drug treatment episodes, and 12.4 (SD=11.2) convictions and 51.3 (SD=52.7) months of incarceration. Of the 56 participants with available Structured Clinical Interview for DSM-IV Diagnoses²³ data, all participants met criteria for a lifetime alcohol use disorder and most (n=44, 78.5%) met criteria for two or more additional SUDs. In the 90 days prior to the current incarceration, participants reported being completely abstinent from alcohol and drugs on 31.4% of days (SD= 32.6).

Themes

Individuals in jail appreciated the opportunity to talk individually about substance use.

Across both randomized conditions, participants expressed appreciation for the opportunity to talk with someone one-on-one and that this was “most helpful” to some (e.g., “Being able to speak”; “Expressing myself”; “The most helpful part was the opening up of my emotions”). In the motivational intervention, participants were given the opportunity to have an open discussion about their alcohol and drug use for the full sixty-minute intervention where therapists tailored the conversation to the participant. One participant who received the motivational intervention remarked, “I liked that they asked about my situation rather than treating [it] like every other situation.” In the educational intervention, participants expressed liking the format of watching videos complemented with discussion: “I liked the discussion before, during, and after the video. I found it very helpful and insightful.”

Participants felt that the interventions increased their self-awareness and expanded their thinking.

In both interventions, participants reported the session helped identify patterns in their own alcohol and drug-related behaviors, which they perceived as beneficial. For instance, two participants noted that the “most helpful” part of interventions was “Recognizing behavior patterns” and “Identifying what makes me stay clean.” Other participants stated that the interventions helped them appreciate the severity of their substance use, which was valuable to them: “just making me realize how much of a [sic] issue my drug problems are.”

Specific tools from each intervention were useful.

There were unique features of each of the intervention protocols participants perceived as helpful. From those in the motivational intervention, many expressed appreciation with the opportunity to explore and discuss their goals and plans for their substance use after they are released. Examples of this theme were: “I enjoyed the opportunity to talk openly about my plan for sobriety when I am released from [jail]” and “Reiterating my plans upon release. It helped to go over with someone what I want to do when released.” Participants who received the motivational intervention also made suggestions to increase specific aspects of this intervention in the future. One participant in this condition recommended “More time,” while another suggested that, “Talking about my experiences and what coping skills would be most helpful [for future interventions].”

Those in the educational intervention similarly reported specific parts as beneficial and recommended increasing them for interventions in the future. Namely, participants found it “most helpful” to watch videos, be exposed to research on addiction, and learn from the quizzes on video content. For example, on participant stated: “The videos were very helpful in going into detail about addiction. [The interventionist] was helpful in breaking down the questions in detail as well.” Additionally, another responded that the “most helpful” part of the educational intervention was: “I learned what I’m doing to my brain.” Participants encouraged the use of these and similar types of videos for future interventions: “More videos on how drugs, alcohol destroys [sic] lives. And people who recover”; “Getting more info on what parts of the brain we are hurting and loosing [sic] as well. It might be very helpful”.

Interventions were encouraging to participants and elicited hope.

Interacting with therapists individually in the motivational intervention was encouraging and learning more about recovery from substance use problems from the videos elicited hope; both of which participants said were some of the most useful parts of the interventions. A participant in the motivational intervention reported that the “most helpful” part was, “Being reinforced that I can actually do this.” Another person noted that “Positive feedback on past behavior, cycle of my alcohol/drug use” was the most beneficial part. For those in the educational intervention, one participant noted, “I am happy knowing that my brain can recover from my drug use” and another commented, “The video gave me hope that there are people actually researching this problem.”

Most aspects of the intervention were perceived as being helpful by participants.

Across all three questions that assessed the most and least helpful parts of both interventions, as well as suggestions for future interventions, many responses reflected that most or all aspects of the interventions seemed beneficial. Examples of answers provided to the questions on the most and least helpful parts of either intervention included: “I would have to say that every aspect of the meeting had some good quality to it,” “Honestly I can’t say any of the meeting was least helpful,” and “None of it. All the meetings was [sic] very helpful to me. Thank you.” Similarly, when asked about recommendations for improving these types of interventions in the future, various participants stated: “Can’t think of anything that needs improvement,” “There wasn’t a part of this study that I was uncomfortable with was rather helpful and insightful [sic],” and “I liked the meeting the way it was.”

A few barriers could be addressed to increase the perceived helpfulness of the interventions.

Regardless of intervention condition, several aspects of the assessment process were identified as parts that were “least helpful” and as things to change for future interventions that could apply to research in general. For example, participants reported disliking the amount of paperwork and assessment material the study required: “All the paperwork,” “the million over and over questions.” Further, despite asking for feedback about the interventions specifically, when answering what part was “least helpful,” participants noted a particular dislike of the timeline followback assessment (Form-90)²⁸ as an onerous tool for collecting quantity and frequency alcohol and drug use data on the daily level: “Remembering all the dates and how many times I used or How [sic] much I used.” Similar, another said, “When and how I used my [drug of choice] 2.5 years ago was a little stressful trying to remember.”

Participants in the motivational intervention critiqued the lengthiness of the interview and shared that it could be sometimes difficult to talk about particular memories. For instance, one participant stated “Make it shorter” whereas another participant detailed “Don’t have a set time on the recorded version. I didn’t know what to say but I was trying to fill up the hour.” When asked about the “least helpful” part of the intervention, a participant stated that it was “Relieving [sic] a bad time in my mind.” For participants in the educational intervention, some participants reported a desire to change the “science part” and “the videos.”

Across treatment conditions, several participants recommended providing individuals in jail with tangible resources as a way to improve future interventions. For instance, when eliciting suggestions for future interventions, various participants responded with: “To have more options of help,” “If it was something that could benefit me right when I get out. If I was actually getting help,” and “More ways to help than a sheet of paper,” which referred to the substance use treatment referral sheet given at the end of both interventions.

Discussion

Results from this qualitative study provided information on feedback to brief alcohol-related interventions from individuals in jail that can be used to inform the development and enhancement of future treatments by incorporating the values of the recipients. Participants appreciated being able to talk individually with a therapist and express their personal stories, perceived specific parts of both interventions as being helpful (e.g., planning, watching psychoeducation videos), and noted that both sessions elicited hope and were encouraging. In sum, participants consistently reported that most/all aspects of the interventions were in some way helpful. Suggestions for improving future interventions also were identified, including reducing the number and extensiveness of data collection measures, making it possible to have interventions be shorter, and providing tangible resources with multiple treatment options for after release from jail.

Treatments in jails need to be brief, but outcome studies so far have shown limited to no benefit, and researchers highlight the need to adapt treatments for this population and setting;¹⁶ these data provide a resource that can be used to enhance the gains seen from existing substance use treatments with individuals who are incarcerated. Specifically, findings from this small qualitative study suggest treatments should be developed to give individuals in jail with substance use disorders the opportunity to speak and plan for release, including personalizing discussions to the individual and offering encouragement to follow through with these plans. Across conditions, participants reported that talking with someone else was helpful, whether it was about themselves or videos. These findings suggest the possibility that talking or interacting with someone else may be an important component of a future intervention. Thus, future interventions may wish to rely on in-person meetings, as opposed to more impersonal formats (e.g., web-based or mobile interventions). Future studies also should include other comparison conditions, such as an assessment-only condition, to help determine if speaking with individuals who are incarcerated at all leads to behavior change or if the content of these interactions may be more important.

As others have identified, individuals who are incarcerated often face many systematic and environmental challenges when they are released.^1,29 Participants from this study expressed an interest in receiving tangible resources beyond treatment referrals. While not specified in participant responses here, tangible resources may include housing and employment opportunities. Participants also noted preferences to make session lengths flexible, with some asking for more time and others requesting less. Offering flexible lengths of sessions has the added benefit increasing efficiency and use of therapists’ time. Finally, even when there are not enough resources for individuals who are incarcerated to meet one-on-one with a therapist, providing psychoeducation in a group format could be appreciated and potentially helpful.

The current study aims to highlight recipients’ feedback to the interventions as a useful tool for treatment development, which is consistent with community-based participatory research princples¹⁷ and shared decision making approaches,³⁰ to studying and treating alcohol and other substance use disorders. Specifically, community-based participatory research principles prioritize the inclusion of recipients in the development of treatments, or in the adaptation of treatments created by researchers. Similarly, the shared decision making approach to alcohol and other substance use treatments promotes individualizing treatment (e.g., informing participants of their disorders and encouraging their involvement in related-goals).³⁰ An inherent problem with the dissemination of treatment in large-scale facilities, such as jails, is that the one-size-fits-all method may have little to no perceived benefits for its intended recipients. This study is one of few to assess the personalized feedback to brief alcohol treatments from individuals in jail with the goal of incorporating it into future treatment efforts with this population.

Although the gold-standard in alcohol treatment research, participants noted the burden of common assessment tools, such as calendar methods for measuring detailed substance use. In particular, it may be difficult for individuals to recall their substance use before they were incarcerated, which may have been many months prior to the interview, and is unique to this population. Thus, the findings from this study have implications for future research with this group. When possible, assessing aggregate outcomes of substance use, such as weekly or monthly values versus daily use, can help to reduce the time and mental encumbrance on participants. Alternatively, researchers should consider limiting their measures to only the most important outcomes or administer assessments across multiple interviews.

There are limitations to the current study. Most notably, qualitative findings offer detailed, personalized information from participants rather than broad, population-based data, which limits the generalizability of the results. Further, the sample size was small and sampled only individuals from one detention center, which could add bias specific to geographic location. Only sentenced individuals with substance use involvement and related charges were included; therefore, results may not be representative of all individuals in jail who could benefit from non-substance use-specific treatments or those individuals with more severe offenses, such as violent crimes, or those with sexual offenses. Inclusion criteria targeted those who were drinking just prior to incarceration; thus, results may not generalize to those who only use drugs. Further, individuals were included if they had any kind of substance use-related charge, largely because it was not always possible to separate alcohol from drug use-related charge; however, this limits how this sample can be characterized and understanding if participants had experienced negative consequences from their alcohol versus drug use versus both. Additionally, post-intervention questions of “helpfulness” were very broad and open-ended and did not explicitly ask about the intervention components. Moreover, participants did not have extended time to consider their responses. This issue may have limited the detail or content they provided overall and specific to the interventions. Finally, responses to what was “most” or “least helpful” were not linked to participant outcomes; therefore, the actual helpfulness of these components could not be determined.

Given the substantial intersection of substance use and legal involvement, individuals in jail with substance use disorders are part of a high-risk population that stands to benefit from refining existing treatment options, particularly those that can be delivered in a brief format. This study utilized community-based participatory research-like principles to assess participants’ feedback after completing either a single motivational or educational intervention focused on alcohol and other drug use. Although there were no between-group benefits observed in the primary trial, these and other interventions could be modified using this feedback, which could help lead to observed improvements. Participants reported that talking to someone individually was helpful, as were educational videos on addiction, but noted that decreasing research assessments and providing more accessibility to tangible resources could improve the perceived helpfulness of these interventions. Findings from this study help provide a voice to individuals in jail with substance use disorders, a group that often is forgotten and underrepresented in the literature, which have important implications for improving treatments and research with this population.