HEALTH-RELATED QUALITY OF LIFE AMONG COMMUNITY-BASED OFFENDERS: HOW ‘WELL-BEING’ AFFECTS SUBSTANCE ABUSE TREATMENT ENGAGEMENT

Abstract

Substance use disorders (SUDs) among community-based offenders are a significant challenge for criminal justice agencies. SUDs are linked with both adverse health risks and increased risk of recidivism. Given the consequences of SUDs, mandated substance use treatment is often required in community supervision. Unfortunately, relapse is extremely common regardless of whether treatment is a condition of supervision. Previous research has identified some factors that can influence treatment outcomes among offender populations, including demographic differences, substance use history, mental health conditions, and criminal history. This dissertation will argue that a more nuanced understanding of the role of health and well-being among community-based offenders is a necessary component in understanding treatment engagement. Health Related Quality of Life (HRQOL), a construct to gauge health and well-being, is often used among medical communities to better understand health impacts on a given population as well as decision-making in treatment compliance studies. However, HRQOL is rarely studied in criminal justice, and has almost never been examined in community offender populations. A robust understanding of health is needed for this population of vulnerable offenders, an understanding that includes multiple dimensions of health including HRQOL. This study sampled a total of 103 offenders from drug court and probation settings, who were mandated to participate in substance use treatment. The health and treatment experiences of this sample of offenders were examined using mixed methods, beginning with quantitative analyses including descriptive, bivariate, multivariate statistical models and structural equation models. The multivariate models and structural equation models examined two main treatment engagement outcomes: whether offenders stayed in treatment and the proportion of treatment sessions attended. These quantitative findings were followed by qualitative analysis of 10 interviews with a subsample of the survey participants who had experienced some level of health difficulty at their baseline survey. Qualitative analyses sought to elaborate on the quantitative findings to provide context for how and why participants were or were not engaging with their mandatory treatment. Results from the quantitative analysis indicate that although criminal history is the most consistent factor influencing treatment engagement, various aspects of health appear to influence treatment success to some extent. HRQOL may influence whether participants stay in treatment. Treatment experiences and health also appear to differ substantially depending on the offenders’ primary drug of use. Offenders who exclusively used marijuana were substantially healthier than their harder drug using peers, and they appear to stay in treatment more easily. Furthermore, both mental and physical health conditions appear to influence treatment attendance among participants who used drugs other than exclusively marijuana. Finally, there were differences in treatment retention depending on whether participants were supervised by drug court or probation, such that drug court participants were more likely to stay in treatment; however, supervision type did not influence proportion of treatment sessions attended. Qualitative findings both provided support for some of the quantitative findings and also illuminated the nuances of the treatment engagement experience of offenders with health difficulties. Interviewees who primarily used marijuana tended to have less severe health difficulties and many did not perceive their use as problematic. Treatment engagement among participants was influenced by their motivation for treatment, whether they had mental health and/or physical health difficulties and the severity of those health difficulties. Logistical factors also influenced treatment engagement, particularly conflicts between treatment requirements and employment and familial relationships. Many of the results presented herein are exploratory and thus require replication; however, some clear directions for future research arise. There is a need to examine the role of health among community based offenders and their ability to comply with mandated treatment with a larger sample. In particular, studies are needed, which include more participants who use ‘harder’ illicit drugs such as opioids and cocaine, as they appear to have more difficulties both with their health and with treatment engagement. Further research is needed on models for Treatment Engagement that include multiple dimensions of health and allow for recursive relationships between health dimensions. Regarding policy and practice implications, the correctional agencies involved should consider re-evaluating the means by which offenders are assigned to supervision and SUD treatment. In particular methods for screening and assessment of SUDs should be re-evaluated, with particular consideration given to the role of offenders’ primary drug of use.