Drug treatment program compliance and resistance activities during implementation of California's Proposition 36.
The Substance Abuse and Crime Prevention Act (SACPA), also known as
Proposition 36, was implemented statewide in 2001 in California. This
legislation remands non-violent drug offenders to drug treatment rather
than prison or jail.
Structured telephone interviews were conducted with a purposive sample of 72 drug treatment programs from six Southern California counties concerning compliance and resistance activities during implementation. A linear regression model was developed that used a dependent variable capturing overall experience with Proposition 36 and compliance and resistance activities as independent variables. 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. The implications of these findings in the context of organizational compliance and resistance activities are discussed.
Illegal drugs (Laws, regulations and rules)
Illegal drugs (Health aspects)
Pharmaceutical industry (Laws, regulations and rules)
|Publication:||Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2009 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739|
|Issue:||Date: Summer, 2009 Source Volume: 32 Source Issue: 1|
|Topic:||Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation|
|Product:||Product Code: 7754000 Illicit Drugs; 2834000 Pharmaceutical Preparations NAICS Code: 325412 Pharmaceutical Preparation Manufacturing SIC Code: 2833 Medicinals and botanicals; 2834 Pharmaceutical preparations|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
In November 2000, California voters approved Proposition 36, the "Substance Abuse and Crime Prevention Act of 2000 (SACPA)." This measure marked major changes to state law so that non-violent adult offenders who use or possess illegal drugs receive treatment rather than incarceration or probation with treatment. The California Department of Alcohol and Drug Programs promulgated guiding principles for the implementation of Proposition 36 statewide (Jett, 2001).
As of this writing, outcome data on offenders undergoing treatment under Proposition 36 are limited, but "best practices" are starting to be identified (Hser et al., 2003). 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 County of Los Angeles Department of Health Services, 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 number of licensed programs statewide, with certified residential programs increasing by 17 percent and certified outpatient programs increasing by 81 percent (State of California Department of Alcohol and Drug Programs, 2002).
Early problems with Proposition 36 implementation have been noted by Spieglman, et al. (2003), including underestimation of the severity of addiction found in clients remanded under Proposition 36, and procedural differences between counties in the interface between the criminal justice system and the drug treatment system. Evans and Longshore (2004), and Wiley, et al. (2004) also explored the differences in clients served by drug treatment providers both before and after Proposition 36, to understand the needs of clients remanded under Proposition 36. Auerhahn (2004) examined whether Proposition 36 would meet the goal of reducing the overall numbers of prisoners within the state correctional system.
Public administration research has always been interested in implementation of publicly funded programs. One approach to assessing implementation successes, failures, and unintended consequences is a case study approach exemplified by Pressman and Wildavsky (1984) and Moore (1997). As the trend toward outsourcing of core functions of government to other sectors (non-profit and for-profit organizations) through the contracting process has become an established practice, research has focused on the impact this outsourcing has had on both service delivery and on the organizations involved (Bigelow & Stone, 1995; Townsend, 2004). Hardy, Teruya, Longshore, and Hser (2005) used Winter's implementation framework to explore these service delivery issues in their qualitative work on implementation of Proposition 36.
Resistance and Compliance
Once a 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 promulgated in the legislation and interpreted and operationalized in the contracts awarded to them by the county in which they operate. However, as organizational actors, drug treatment programs may resist certain aspects of Proposition 36 and/or comply with its other aspects. Some aspects of Proposition 36 may be viewed by the organization as something that can be adapted without change or effort. Other aspects of Proposition 36 may require that the drug treatment program resist. The actual mix of resistance and compliance activities any one drug treatment program will choose will depend upon that program's current mix of practices, values and need for the resources offered as funding as part of participation in Proposition 36.
Bigelow and Stone (1995) found that values of the staff employed by nonprofit community health centers were often at odds with the requirements of the funding agencies. "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 ... "(p. 3).
Hypothesis 1: Resistance and compliance activities will be associated with the values of the program.
Compliance and resistance activities have been identified as integral parts of organizational functioning at both the micro (individual) and macro (organizational) levels. At the organizational level, Thompson (1967), Oliver (1991), and Scott (1967) all theorize that organizations will differentially moderate the influence that the environment has on organizational functioning. One reason for this is that all organizations are constrained in their ability to respond to environmental influences because of their structure. Wicks' typology of compliance and resistance identifies them as "behavioral responses to constraining elements of structure" (1998).
Hypothesis 2: Differences in the structure of participating drug treatment programs will influence their resistance and compliance activities.
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. Interviews were conducted with key informants who were individuals identified in each drug treatment program as being familiar with Proposition 36 implementation in their program. The textual analysis of these qualitative interviews has been described elsewhere (Reynolds, 2008). The results of these interviews identified resistance and compliance activities and these are summarized in Table 1.
Telephone interviews were undertaken in this phase of the research to determine whether the findings from the qualitative interviews would generalize to a larger sample of drug treatment providers. Because compliance and resistance activities were identified from the qualitative 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 purposive sample of drug treatment providers from six counties in Southern California. These programs were identified as Proposition 36 providers with current county funding to provide services under Proposition 36. All programs were also licensed by the State of California, Department of Alcohol and Drug Programs, to provide substance abuse treatment services. Each respondent was invited to complete the interview was either the Proposition 36 coordinator for the program or another staff person knowledgeable about Proposition 36 implementation and activities within the drug treatment program.
The final data set consisted 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 took approximately 15 minutes to administer. The questions elicited demographic information on both the drug treatment program (whether it offered outpatient or residential services under Proposition 36 (or both); 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 work on Proposition 36; if the answer to this question was "yes," then a follow-up question concerning the type of staff position that the program hired was asked, (counseling staff, intake staff, administrative staff or 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); and on the respondent (gender, number of years working drug treatment, educational level) .
The questionnaire also 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 included: 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 questionnaire also presented a series of statements that the respondent was asked to rate on a one (1) to five (5) Likert-type scale, with 1 being total disagreement with the statement and 5 being very strong agreement. The statements 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 assessments done by the County or the assessment centers when placing the clients; problems with "no show" clients; the degree to which clients understood 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 Likert-type scale were used to determine the values 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 program relies on ex-addicts with experience of addiction 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 philosophy of total abstinence in program service delivery.
The dependent variable on overall program experience was "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." 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 would be skipped. Table 2 shows the breakdown of programs by county that participated in the telephone interviews.
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.
Multiple linear regression was used to develop a regression model using program satisfaction with Proposition 36 as the dependent model and resistance and compliance activities, program demographics, funding concerns, perceptions of clients remanded through Proposition 36, adequacy of training, confidence in the assessments done by the counties on clients, and respondent demographics as independent predictor variables. All analyses were conducted using the SAS system.
Program and Respondent Descriptions
The majority of programs interviewed by telephone were experienced in the delivery of Proposition 36 services. Table 3 shows the characteristics of the participating programs and respondents.
Compliance and Resistance Activities
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 new staff. For those programs that indicated that they had hired new staff, the most frequently mentioned staff position that was hired to work on Proposition 36 was counseling staff (20 programs hired counseling 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.
The most common resistance activity reported by programs was re-doing the Addiction Severity Index or other assessment of clients coming into the program. Table 4 summarizes the results for compliance and resistance activities.
Residential programs were also significantly less likely to change the hours that groups or counseling sessions met to accommodate Proposition 36 clients ([[??].sup.2](1) = 9.04, p = .0026). They were less likely to have increased the caseloads of counseling or case management staff to accommodate additional Proposition 36 clients ([[??].sup.2](1) = 3.33, p = .06) and were less likely to have created a separate treatment track just for the Proposition 36 clients ([[??].sup.2](1) = 3.07, p = .07), though neither of these findings reached statistical significance.
Outpatient programs were significantly more likely to have established a separate treatment track for the Proposition 36 clients ([[??].sup.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 ([[??].sup.2](1) = 13.89, p = .0002). They also were more likely to have changed the length of their standard treatment modality to conform to Proposition 36 standards ([[??].sup.2] (1) = 2.97, p = .08), and were more likely to have increased the caseloads of counseling or case management staff to accommodate more Proposition 36 clients ([[??].sup.2] (1) = 3.50, p = .06), though these two findings did not reach statistical significance.
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.
A multivariate linear regression model was fit to the data using the dependent 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." Three variables were included in this parsimonious regression model, which is provided in Table 5. The model was significant (F (3) = 4.94, p = .044) and accounts for 22.8 percent of the variance in the outcome variable as shown in Table 6.
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 is also negatively associated with the overall Proposition 36 experience.
Limitations of the Research
There are several limitations of this study that must be acknowledged. First, data collection for the telephone interviews occurred over several months. Data collection started around May 2003 and continued through November 2003. During this time, several things occurred in the environment of 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.
Second, the instrument used in the telephone interviews has not been tested for reliability and validity, so the conclusions drawn from data derived from it must acknowledge this shortcoming. Third, the sample of individuals interviewed for the research was not random and it is possible that different responses would be elicited from a different set of respondents. Four, the sample size of programs was small, representing about 25 percent of the drug treatment programs operating at the time of the interviews. Finally, the experience of drug treatment providers in the Southern California counties related here is not generalizable to all counties in California as the implementation of Proposition 36 was decentralized, and counties had wide latitude in implementation within their local jurisdictions.
This research identified activities undertaken by drug treatment programs during implementation of Proposition 36. It identified compliance and resistance activities within an open systems framework to describe and investigate drug treatment program behavior. The main findings of the regression model indicated that compliance activities could be either negatively or positively associated with overall program experience with Proposition 36 during implementation. Two compliance activities, hiring new staff and obtaining additional space for operations, were negatively associated with overall program experience, as indicated by the negative sign on the parameter estimates in the regression model. This would indicate that the drug treatment programs' overall experience with implementation of Proposition 36 was more the result of actions undertaken by the drug treatment program rather than actions undertaken by the State of California or the County within which the drug treatment program was located. Activities such as hiring new staff and acquiring additional space are usually determined by program management, and not dictated by outside organizations.
Such activities are also inherently stressful to organizations. Hiring new staff requires that advertising for the staff position(s), recruitment, interviewing and training all be undertaken. These activities are time consuming and draw organizational resources away from programmatic activities, at least in the short term. Acquiring additional space is also an inherently stressful activity. Potential space must be sought out, an on-site visit must taken place, and leases or purchases must be negotiated. Once the additional space has been identified and acquired, movement of staff and offices to the new location must be arranged and coordinated. Like hiring new staff, acquiring additional space also takes time and draws resources away from daily programmatic activities and can cause disruption in the short-term. That the need to undertake compliance activities that are disruptive to normal organizational functioning is negatively associated with overall program experience with Proposition 36 makes sense; even if the disruption in the short-term allows the program to provide better services to more clients in the long-term, the disruption is real to program staff while it is happening.
One compliance activity, sharing problems and solutions with other treatment providers, was positively associated with overall program experience of Proposition 36. This is consistent with previous research by Alexander (1995), who found that organizations that established cooperative relationships with other similar organizations were better able to cope with changes in the larger environment when they occurred. Townsend (2004) found that networks that included criminal justice and drug treatment providers were better able to coordinate a broad range of services and case management activities for drug abusing women with misdemeanor and felony criminal justice involvement. Again, the decision to participate in such cooperative relationships would be the result of decisions by program management, and not by outside entities. Most of the counties provided public meetings and forums for drug treatment programs to meet with county officials and voice their concerns about Proposition 36; however, the decision to attend such forums was up to the management of the drug treatment programs and their staff.
It is not surprising that outpatient drug treatment programs were those most likely to engage in many of the compliance activities, such as changing the hours that counseling sessions met, hiring new staff, acquiring additional space, and changing the length of the standard treatment modality. Outpatient programs have greater flexibility than residential programs in the number of clients they can serve. They are not constrained to as great a degree as residential providers are by space requirements, as they are not providing living accommodations for clients as the residential program are. As such, outpatient programs can take on additional clients fairly easily, increasing the size of caseloads of existing staff, hiring new staff to take on additional clients, and they can add additional individual and group counseling sessions, during the day, during evening hours, or on weekends. This research found that hypothesis 2 regarding organization structure was supported by the findings.
This research also found that program demographic variables, respondent demographic variables, variables that elicited information on perceptions of the clients remanded into the drug treatment program under Proposition 36, and the financial concerns variables were not significantly associated with overall program experience of Proposition 36. The values of the organization, including use of professional staff compared to using ex-addicts, were not associated with overall program experience. Hypothesis 1, that compliance and resistance activities would be associated with the values of the program, was not supported.
The important finding from this research for public administrators is the empirical support for the interorganizational and network approaches of Alexander (1995) and Townsend (2004). Facilitating the ability of programs to share problems and solutions with each other appears to be an important component of the overall Proposition 36 experience.
Government contracting for the provision of services is an established practice. This research, like that of Oliver (1991) indicates the importance of considering compliance and resistance behavior on the part of agencies that are contracted to provide public services in understanding how those agencies respond to the demands placed on them.
Alcohol and Drug Programs County of Los Angeles Department of Health Services. (2004). Substance Abuse and Crime Prevention Act of 2000: Proposition 36 Annual Report 2002-2003. Los Angeles, CA: Department of Health Serviceso. Document Number)
Alexander, E. R. (1995). How Organizations Act Together: Interorganizational Coordination in Theory and Practice. Amsterdam, The Netherlands: Gordon and Breach Science Publishers S.A.
Auerhahn, K. (2004). California's incarcerated drug offender population, yesterday, today and tomorrow: Evaluating the war on drugs and Proposition 36. Journal of Drug Issues, 34(1), 95-120.
Bigelow, B., & Stone, M. (1995). Why don't they do what we want? An exploration of organizational responses to institutional pressures in community health centers. Public Administration Review, 55(2), 183-193.
Evans, E., & Longshore, D. (2004). Evaluation of the Substance Abuse and Crime Prevention Act: Treatment clients and program types during the first year of implementation. Journal of Psychoactive Drugs, SARC Supplement 2, 165-174.
Hardy, M., Teruya, C., Longshore, D., & Hser, Y. (2005). Initial implementation of California's Substance Abuse and Crime Prevention Act: Findings from focus groups in ten counties. Evaluation and Program Planning 28, 221-232.
Hser, Y., Yeruya, C., Evans, E., Longshore, D., Grella, C., & Farabee, D. (2003). Treating drug-abusing offenders: Initial findings from a five-county study on the impact of California's Proposition 36 on the treatment system and patient outcomes. Evaluation Review, 27(5), 479-505.
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Speiglman, R., Klein, D., Miller, R., & Noble, A. (2003). Early implementation of Proposition 36: Criminal justice and treatment system issues in eight counties. Journal of Psychoactive Drugs, SARC Supplement1, 133-141.
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Townsend, W. A. (2004). Systems changes associated with criminal justice treatment networks. Public Administration Review, 64(5), 607-617.
Wicks, D. (1998). Organizational structures as recursively construed systems of agency and constraint: Compliance and resistance in the context of structural conditions. Canadian Review of Sociology and Anthropology, 35(3), 369-390.
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California State University, Long Beach
Table 1. Compliance and resistance activities identified in phase i interviews Compliance Activities * Attending county meetings * Attending training (on shared data system, etc) * Hiring staff * Acquiring additional space * Increasing caseloads of staff * Acquiring additional space * Changing length of TX * Changing hours that groups/counseling sessions meet * Sharing problems and solutions with other treatment providers * Upgrading/purchasing computers * Bringing concerns to county's attention * Increasing the number of clients * Creating a separate treatment track only for Prop 36 clients* Resistance Activities * Urine testing despite lack of funding (first year only) * Re-doing Addiction Severity Index or other assessment * Sending clients back to the Community Assessment Centers * Creating a separate treatment track only for Prop 36 clients* * Both a compliance and a resistance activity, depending on context Table 2. 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 Table 3. Telephone interviews: Participating programs and interview respondents N (%) Mean (SD) Year Received First Prop 36 Client 2001 51 (76) 2002 13 (19) 2003 3 (4) Type of Program Outpatient only 41 (59) Residential only 14 (20) Both residential and Outpatient 15 (21) Program Size (# of clients) Outpatient 55 (47.28) Residential 27 (8.18) Program Size (# of staff) Outpatient 8.97 (8.28) Residential 16.07 (18.52) How Frequently Staff Meetings Occur Weekly 48 (67) Monthly 14 (20) Less than monthly 9 (13) Respondent Gender Male 38 (54) Female 32 (46) Years Working in Substance Abuse TX 10.07 (8.16) Years Working/Current Program 5.15 (5.14) Table 4. Telephone interview results: Compliance and resistance activities Activity (Type) Total "Yes" % "Yes" 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) Re-do ASI or other Assessment 44 65.7 (Resistance) Table 5. Final regression model predicting overall experience with Proposition 36 Variable B SE B  Intercept 8.47 1.15 0 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, R-squared = 22.8
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