Psychosocial treatment for incarcerated

methamphetamine users: the Philippines

experience
Ma. Regina M. Hechanova, Jennel C. Reyes, Avegale C. Acosta and Antover P. Tuliao

Abstract Ma. Regina M. Hechanova

Purpose – The purpose of this study is to evaluate a psychosocial treatment program for prisoners is based at the Department
incarcerated because of methamphetamine use. It compared the outcomes of prisoners who received of Psychology, Ateneo de
the program while incarcerated, those who were released and received the treatment as part of Manila University, Quezon
community-based drug recovery program and a waitlist-control group (WC) with no treatment. City, Philippines, and
Design/methodology/approach – The study used quasi-experimental design was used with pre- and University Research Co.,
post-test surveys administered to three groups: a WC group, a pre-release treatment-while-incarcerated LLC, Bethesda, Maryland,
(TWI) group, and a post-release outpatient treatment group (OP). Surveys measured recovery skills, life USA. Jennel C. Reyes and
skills and substance use disorder (SUD) symptoms were administered before and after the intervention.
Avegale C. Acosta are both
Findings – Results revealed that at baseline OP and TWI had significant higher recovery skills compared based at the Department of
to WC group. However, in terms of life skills, there was no significant difference was observed among the Psychology, Ateneo de
WC, OP and TWI group at baseline. TWI had a significantly lower number of SUD symptoms compared to
Manila University, Quezon
the WC group at baseline. As hypothesized, findings revealed significant changes in recovery and life
City, Philippines.
skills among the OP and TWI group compared to the WC group. No significant change in SUD scores
were observed for all groups. Antover P. Tuliao is based
at the Department of
Research limitations/implications – A major limitation of the study was the use of a quasi-experimental
Community Family and
because legal issues did not allow randomized control trial. Future research using randomized controlled
trial designs would provide more robust conclusions on the impact of the intervention. The study design Addiction Sciences, Texas
was also limited to pre- and post-evaluation. Further studies are encouraged to look at longitudinal Tech University, Lubbock,
outcomes of on SUD symptoms and possibility of relapse. Texas, USA.
Practical implications – Given that there were no significant differences in outcomes between OP and
TWI groups, results suggest that the program may serve either as a pre- or post-release program for
incarcerated drug users. However, results also suggest that completion is higher when the program is
used as a pre-release program. Delivering the program prior to release also reduces challenges related
to attrition including conflict in schedules and the lack of resources for transportation.
Social implications – The study suggests the value of psychosocial treatment as opposed to punitive
approaches in dealing with drug use. In particular, delivering interventions prior to release can prepare
participants for problems they may encounter during reintegration and prevent recidivism. In a country
where drug-related killings are on the rise, the study presents an alternate and restorative justice approach.
Originality/value – The study addresses a dearth in the literature on psychosocial intervention for
methamphetamine users. It also fills a vacuum in studies from developing countries such as the Philippines.
Keywords Prisoners, Illicit drugs, Psychological health, Philippines, Drug abuse,
Problematic drug use
Paper type Research paper Received 2 September 2019
Revised 11 January 2020
28 May 2020
31 May 2020
Introduction Accepted 1 June 2020

Studies show a dyadic relationship between drug use and incarceration. A study in the USA This study was funded by the
Commission on Higher
revealed that 15% of those who are incarcerated have a history of heroin addiction. It also Education K-12 Dare to
reported that incarcerated offenders with a previous history of addiction tend to relapse Research Grant.

DOI 10.1108/IJPH-09-2019-0044 © Emerald Publishing Limited, ISSN 1744-9200 j INTERNATIONAL JOURNAL OF PRISONER HEALTH j
 within prison, suggesting a need for drug treatment for those with histories of addiction
(Gordon et al., 2008).
Much of the literature on substance use treatment has come from developed countries
where the drug of choice are opioids and has focused on pharmacotherapy treatments.
However, in many developing countries in Asia, the drug of choice is methamphetamine
and, to date, there are no pharmacological treatments for methamphetamine use (Stuart
et al., 2020). Although there is evidence of the efficacy of psychological treatment for
methamphetamine users (Stuart et al., 2020), there is a dearth of literature on psychosocial
treatments for those incarcerated because of drug use (Kinner et al., 2015). Thus, this study
seeks to contribute to the literature by evaluating a psychosocial program for prisoners
incarcerated in the Philippines where the drug of choice is methamphetamine. Specifically,
it compares the outcomes of prisoners who received the program while incarcerated, those
who were released and received the treatment as part of community-based drug recovery
program and a waitlist-control group (WC) with no treatment.

Drug use and incarceration

Substance use disorder (SUD) is associated with criminal activity and incarceration. A
longitudinal study looking at prisoners’ health outcomes found that a history of risky
substance use was normative among prisoners (Kinner et al., 2015). At the same time,
studies show that 10%–48% of men and 30%–60% of women prisoners use illegal
substances while incarcerated (Fazel et al., 2006).
One explanation for the link between substance use in prison is mental health. A study
conducted by Kinner (2006) reported that nearly half (46%) of prisoners reported mental
health below the population norm, with 27% experiencing high or very high levels of
psychological distress. Thomas et al. (2016) found evidence of mood disorder, anxiety
disorder, history of self-harm and risky drug use as risk factors for prisoners with high to
very high psychological distress. In addition, the majority of prisoners’ psychological
distress continues after release from prison.

Reintegration and recovery Capital

Prisoners with SUDs face a number of challenges upon their release. A major challenge is
their low self-efficacy and inability to prevent relapse post-release. In addition, many
released prisoners return to drug-infested environments with negative peer influences and
experience stigma. Many have fractured family relationships and lack family support.
These, coupled with a lack of access to information and health services and employment
opportunities, often lead to relapse (Haley et al., 2014).
Emotional and practical support from family, friends and community services has been
identified as a significant recovery factor especially for women in their transition from prison.
Those with secure social connections in their community experience more positive
reintegration (Sheehan, 2018). Literature also suggests that prisoners’ pre-release
expectations of their future are associated with their post-release difficulties including
substance use. Realistic views allow prisoners to recognize that they are at risk for adversity
and having a positive mindset or optimistic attitude is linked to active coping and positive
outcomes (Souza et al., 2015). The authors underscored the importance of including
adaptive coping and encouraging a positive outlook in pre- and post-release programs.

Psychological treatments for drug use

Recent developments in drug treatment in developed economies have focused on
pharmacological treatments specifically for abuse of opioids. For example, there is robust
support for the use of opioid agonist therapy using methadone as an effective means of

j INTERNATIONAL JOURNAL OF PRISONER HEALTH j

reducing heroin addiction (Gordon et al., 2008). A study on opioid substitution treatment
among prisoners in England showed that it was linked with a 75% reduction in mortality and
85% reduction in drug-related poisoning mortality (Marsden et al., 2017). Studies that
tested the impact of pharmacological treatment and counseling reported that inmates who
received a combination of counseling and methadone treatment are more likely to have
more days in treatment post-release and less criminal activity post-release compared to
those who just received counseling (Gordon et al., 2008).
In terms of psychological interventions, there is evidence of the efficacy of cognitive
behavioral therapy (CBT) (Prendergast et al., 2017) and motivational interviewing (MI) in
treating substance use (Stein et al., 2002). Both CBT and MI appear effective for
methamphetamine users as well. A review of psychological treatment for methamphetamine
users reported that CBT, MI and the matrix model (an eclectic model that combines CBT
and MI) have the greatest empirical support for effectively decreasing methamphetamine
use and its psychiatric symptoms (Stuart et al., 2020).
Stuart et al.’s (2020) review revealed a range of treatment programs from brief to 36-session
interventions. They conclude that more intensive interventions may be beneficial compared
to brief or less intensive interventions. However, they acknowledge the issue of consistency
of attendance is an important factor. They reported attrition rates in outpatient programs
range from 25%–60% with higher attrition for longer programs.

Drug treatment for prisoners

Many prisoners who are dependent on illegal substances also do not receive any TWI or
upon release thus leading to a cycle of relapse, recidivism and re-incarceration (Gordon
et al., 2008). A study shows that prisoners that are dependent on substances face acute
risk of death particularly in their first year of release (Kinner et al., 2012).
However, there is some evidence that MI and CBT are effective treatments in controlling
substance use among prisoners post-release (Stein et al., 2002; Newbury-Birch et al., 2016;
Clarke et al., 2011). However, one study showed that although a brief two-session
intervention increased abstinence up to three months post-release, its effect decayed
six months after participants returned to the community (Stein et al., 2010). The authors
suggest the need for more intensive pre-release and re-entry intervention for incarcerated
substance abusers (Stein et al., 2010).

Drug use in the Philippines

The issue of drug use, incarceration and treatment is salient in the Philippines where drug
use is a crime. In 2016, it became a centerpiece of President Duterte’s administration when
he launched a campaign against illegal drugs The campaign involved house visits to
suspected drug offenders (pushers and users) to convince them to “surrender” for
treatment (Romero, 2018). As of March 2019, more than 1.4 million users have reported to
have voluntarily surrendered (Galvez, 2019). The number of drug arrests also spiked with
the Philippine Drug Enforcement Agency reporting that 220, 728 were arrested from July
2016 to November 2019 (Merez, 2019). In the Philippines, the penalty for possession of 0.01
to 4.99 grams of illegal drugs is 12–20 years of imprisonment. For those caught with more
than 5 g, the penalty is 20 years to life imprisonment. Prison congestion rates rose to 612%
and subsequent overcrowding has caused sickness, disease and even death (Buan, 2018).
To address this, the Supreme Court of the Philippines allowed plea bargaining for offenders
caught with less than 5 g, reducing their jail sentence to six months – four years and
granting conditional release upon completion of a community-based drug treatment
program (Department of Justice, 2018).

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 Unfortunately, the Philippines has no history of community-based programs for substance
users. In response to this need, the Psychological Association of the Philippines
[Psychological Association of the Philippines (PAP), 2019] developed a program for users
who voluntarily surrendered. The Katatagan Kontra Droga sa Komunidad (Resilience
against Drugs in Community, KKDK) is a small-group intervention for persons who use
drugs (PWUDS) with mild-dependence. The intervention was designed based on a study
showing that clients who volunteered for treatment were generally poor, uneducated and
unemployed. Interviews with a sample of PWUDs revealed that two-thirds reported
experiencing adverse childhood conditions and had multiple life problems and poor coping
skills. The data was consistent with the self-medication hypothesis (Khantzian, 1975) that
suggests that people who use drugs do so to relieve or change painful affect states.
A review of the literature on evidence-based treatments concluded that the most successful
treatment programs incorporate strategies to enhance coping, reduce craving, manage
triggers and prevent relapse. In addition to these drug recovery skills, helping people better
manage their difficult emotions, cope with negative life circumstances, enhance social
support for sobriety and establish a life style free of substance use is critical to long-term
recover (Skewes and Gonzalez, 2013). Given this, and the results of the interviews, the
KKDK program was designed to develop recovery and hone life skills. The evidence-
informed program was culturally adapted from materials from the United Nations Office on
Drugs and Crime (UNODC) trainer’s manual on community-based services for people who
use drugs in Southeast Asia and the counselors’ treatment manual on Matrix Intensive
Outpatient Program (MIOP) treatment on Substance Abuse and Mental Health Services
Administration (SAMHSA) (Hechanova et al., 2019). In addition, given the valuable role of
the family in the Philippines and the premise that drug use is not only an individual problem
but also is linked to the family (Hechanova et al., 2018), family modules were created. The
intervention was pilot tested and evaluations revealed that clients reported significant
increases in drug recovery, life skills, family support and psychological well-being
(Hechanova et al., 2019).
To develop an intervention for prisoners incarcerated for minor drug offenses, the research
team conducted a needs analysis, which revealed that incarcerated users had higher SUD
symptoms, used more types of drugs and had lower recovery and life skills. Based on these
findings, an intensive version of KKDK was developed for prisoners who applied for plea
bargaining.
Thus, this study sought to contribute to the literature in two ways. First, it sought to fill the
dearth of literature from developing countries by evaluating the impact of a program on
drug recovery skills, life skills and substance use on incarcerated methamphetamine users.
Second, it examined possible differences between participants in a pre-release program
with those who underwent the program post-release. In addition, the study examined
whether there would be differences in outcomes between those who received TWI and
those who went through the intervention in an outpatient post-release program. Given the
likelihood of attrition in outpatient programs, we suggest that outcomes would be better for
those who receive the treatment prior to their release. Specifically, we hypothesized that:
H1. Participants who attend the program will have improved drug recovery skills
compared to non-participants.
H2. Participants who attend the program will have improved life skills compared to non-
participants.
H3. Participants who attend the program will have decreased drug use compared to
non-participants.
H4. Participants who attend the program while incarcerated will have better outcomes
than those who receive it as an outpatient intervention.

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Method
This study used a quasi-experimental design with pre- and post-test surveys administered
to three groups: a WC group, a pre-release group and a post-release group.

Participants
The sampling plan was designed to facilitate a comparison between a pre-release group
and an outpatient group (OP) who appealed for plea bargaining. The study involved three
groups: a WC group, a TWI group and an OP group. The WC group (n = 121; M = 52%)
were prisoners who had applied for plea-bargaining but whose release had not yet been
approved and who had not yet received the KKDK Intensive program. The TWI group
(n = 63; M = 27%), were plea bargainers who were serving the remaining period of their
penalty in prison. As part of the pre-release program in their city, the plea bargainers had to
complete a psychosocial TWI. The OP group (n = 50; M = 90%), on the other hand, were
plea bargainers who were already released but mandated to complete an outpatient
program in their communities. Table 2 presents the demographic statistics for each group.

Intervention
The program was designed for prisoners incarcerated because of minor drug-related
charges but required to undergo a community-based drug rehabilitation (Hechanova et al.,
2019). The modules were adapted from the UNODC trainer’s manual on community-based
services for people who use drugs in Southeast Asia and the Counselors’ treatment manual
on MIOP treatment on SAMHSA (Hechanova et al., 2019). The resulting intervention
consisted of 24 modules, 18 individual modules focusing on drug recovery and life skills
and six family modules.
The intervention design was based on four theoretical foundations: MI, CBT, mindfulness
and family systems theory. MI is a client-focused approach commonly used in drug
treatment, which assumes that people will not change simply because they are told to do
so. It seeks to build clients’ internal motivation through empathy, increasing the discrepancy
between their ideal and current lives and enhancing self-efficacy and optimism (Miller and
Rollnick, 2013). The first two modules focus on increasing PWUDs’ motivation to change.
Because participants are not yet experiencing negative effects, the first four modules focus
on building motivation to change. The fourth module is founded on MI and seeks to
enhance participants’ motivation to change. Modules 1–3 focus on the effects of drugs and
Module 4 focuses on the importance, readiness and reasons for change.
CBT is one of the most used approaches and has the most robust evidence as drug
treatment (Windsor et al., 2015). Beck et al. (1993) describe drug use as a learned behavior
that can be unlearned by addressing seven areas of psychological vulnerability. These
include honing client’s abilities to manage:
䊏 high risk situations that are both external (people, places, things) and internal (mood
states);
䊏 dysfunctional beliefs about drugs, oneself and one’s relationship with drugs;
䊏 automatic thoughts that increase arousal and intent to use;
䊏 physiological cravings;
䊏 permission-giving beliefs that justify drug use;
䊏 rituals and behaviors linked to substance use; and
䊏 adverse reactions to lapse or relapse.

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 The fifth module aims to help users learn strategies to manage cravings. The sixth module
focuses on helping clients understand their external triggers and the seventh module
develops their refusal skills. The eight module focuses on relapse prevention and
management strategies. The ninth module focuses on holistic health and encourages
participants to identify ways to achieve total well-being. CBT is also used in Modules 10 to
12, which help clients manage negative emotions, thoughts and understand the link
between thoughts, emotions and drug use. Modules 13–15 focus on social health and seek
to hone interpersonal skills and help participants identify ways to rebuild broken
relationships. Module 16 focuses on building problem-solving skills – participants are asked
to reflect on what other aspects of their life are ‘unhealthy’ or problematic and are then
guided through steps in problem-solving. Module 17 focuses on building participants’ self-
esteem and self-efficacy by asking them to reflect on their strengths. The final individual
module focuses on helping participants identify goals and plans to achieve these.
Mindfulness involves the ability to be nonjudgmentally aware of the present moment (Bishop
et al., 2006). It has been found to be useful in relapse prevention and helping drug users
understand their states (Zgierska et al., 2009). In the KKDK intervention, mindfulness
exercises are used to “center” or prepare participants at the start of each module.
Mindfulness is also introduced in the modules on managing cravings, negative thoughts
and emotions.
The family modules of KKDK are based on family systems theory (Minuchin, 1974) and
consist of six family sessions. The sessions are designed to engage family members
and help them better understand the effects of drugs, build their interpersonal skills and
enhance communication and dialogue within the family. The modules also seek to help
family members understand the role family members can play in recovery. The sessions
end with family members envisioning their desired future and planning for recovery as a
family. Table 1 shows the topics and the active ingredients in each session.
The modules were designed so they would be appropriate to Philippine culture and context.
A vast majority (90%) of Filipinos are Christians and spirituality plays a large role in the lives
of Filipino recovering users (Hechanova and Waelde, 2017). Filipinos turn to prayer or
consult with priests/religious leaders when they have problems, experience cravings, stress
or negative emotions (Tuliao and Liwag, 2011). To acknowledge this, ecumenical prayers
are incorporated in some modules and opportunities for prayers are included in the opening
and closing of each session. The module on health uses a framework for holistic health that
includes spiritual health.
Given low literacy rates, the modules use physical and creative activities instead of
worksheets. The manual is written in Filipino and in simple language. Skills practice and
homework are used to reinforce learning and repetition.
Yet another important cultural adaptation is the manner of delivery. The MIOP and UNODC
modules are designed as individual interventions. Given, the Philippines’ collectivist culture,
(Church and Katigbak, 2002) and studies showing that group-based interventions are a
good venue of healing among Filipinos (Hechanova and Waelde, 2017), the program was
designed as a small group intervention.
Finally, the family plays an important role among Filipinos. Filipinos are generally
reluctant to seek professional help because of the fear of being labeled “crazy” or from
a sense of shame in tarnishing the family’s reputation (Tuliao, 2014). A study in the
Philippines reports that openness to counseling is mediated by family and friends
(Tuliao, 2014). Hence, the program includes six family modules to help significant
others understand the nature of drug use, develop communication skills and engage in
dialogue. The modules also focus on the role of the family and how they can support
their family member through recovery.

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Table 1 KKDK intensive modules
Module
Drug recovery skills
1. Orientation
2. Effects of drug use on the
brain and body
3. Understanding the
psychosocial effects of drugs
4. Importance and readiness
for change
5. Coping with cravings
6. Managing external triggers
7. Saying no
8. Relapse prevention
9. Adopting a healthy lifestyle
Life skills
10. Managing feelings
11. Managing thoughts
12. Identifying paths that lead
to drug use and planning how
to avoid it
13. Interpersonal skills:
effective listening
14. Interpersonal skills:
assertive communication
Active ingredient
Understanding the nature of
drug use
Understanding the physical
effects of drug use
Understanding the
psychosocial effects of drug
use
Identifying reasons and
readiness for change
Behavioral strategies to
manage cravings
Identification of external
triggers
Drug refusal skills
Relapse management skills
Identification of the
components of a healthy
lifestyle
Emotion management skills
Thought management skills
Mindfulness of patterns that
leads to drug use and creating Identify the sequence of events (emotions, body sensations, beliefs
a plan to prevent drug use
using lessons learned from the Give appropriate strategies in managing each external or internal event
earlier modules
Effective listening skills
Assertive communication
Expected outcome
Introduce the program and its guidelines
Get to know the members of the group
Describe the reasons why people use and get hooked on drugs
Describe the phases of drug use and signs of addiction
Get to know some neurotransmitters that are influenced by drug use
Determine how drug use affects the body and brain
Reflect on how drug use changed different aspects of their lives
Identify the common misconceptions on drug use
Envision a future without drugs
Discuss their reasons for change
Reflect on the importance of change, confidence in their current
abilities to change and their current readiness for change
Identify and describe what cravings are
Identify thoughts or beliefs, emotions and body sensations that trigger
drug use
Identify strategies to address cravings
Identify people, places, things or events that trigger drug use
Create a concrete plan to avoid or manage these triggers
Clearly identify ways of avoiding people who may lead one to return to
drug use
Practice assertive communication in saying “no” or avoiding drug use
Know the stages of relapse
Reflect and identify their own warning signs to prevent relapse
Create an action plan in managing lapse
Identify their journey toward a future without drugs and how to
strengthen a person’s holistic well-being and health
Analyze their own overall health and give attention to things that they
may need to change
Explain the interacting roles between events and feelings, and know
how these conditions our reactions to unpleasant events
Identify the various feelings that arise whenever unpleasant events are
experienced
Learn various strategies in facing unpleasant feelings
Explain the interacting roles between events and feelings, and know
how these conditions our reactions to unpleasant events
Identify beliefs that are present whenever they experience unpleasant
events
Demonstrate strategies in managing unhelpful thoughts
Remember the events, people, places or things that trigger drug use
and behaviors) that lead to the participant closer to drug use
to leave or avoid the path that lead to drug use
Demonstrate the ability to differentiate between effective and
ineffective listening
Identify effective and ineffective ways of listening
Demonstrate ability to read non-verbals
Practice the different effective listening skills
Discuss elements of effective communication that may lead to
misunderstanding
Identify communication styles (assertive, passive, aggressive)
Practice using assertive communication
Identify situations of stigma experienced by a participant and practice
listening and communication skills in these situations
(continued)
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 Table 1
Module Active ingredient Expected outcome

15. Rebuilding relationships
16. Problem-solving
17. Recognizing my strengths
18. Meaning making and
planning for the Future
Family modules
Family Module 1. Clarifying
and understanding problems
brought about by drugs
Family Module
2. Communication skills
(family members)
Family Module 3. Family
communications
Fam Module 4. Family and
drug use
Fam Module 5. Family
visioning
Fam Module 6. Family in
recovery
Awareness of how they may
have hurt others or others may
have hurt them
Problem-solving skills
Self-knowledge; self-efficacy
Meaning making; hope
Understanding drug use and
how it affected the family; what family
family members can do
Effective listening and
assertive communication skills of misunderstanding
Authentic dialogue drug use
and vice versa
Family support and norms
Instilling hope
Planning and contracting
Talk about the link between drug use and family
Reflect on the possible pain they may have inflicted on their loved ones
Reflect on the possible pain that their loved ones inflicted on them
Reflect on whether they are ready to forgive and/or ask for forgiveness
Identify one’s key problem on drug use
Share what the barriers are in solving one’s drug problem
State the different possible solutions to solving one’s problem
Choose the best solution to one’s problem
Describe what they have been through and what they have learned
about themselves
Notice the progress or growth that happened to them ever as they
started with the program
Reinforce their strengths
Reflect on the meaning on of their experiences
Describe their dreams in life
Set specific goals for the next months or years based on their dreams
in life
Identify concrete steps toward achieving their goals
Share what they have gone through as members of the drug user’s
Clarify the causes, effects of drugs and the root of drug use in the
family
Express what can be done to support their relative’s recovery
Explain the elements of effective communication which may be causes
Demonstrate effective and ineffective ways of communicating
Demonstrate effective and ineffective ways of listening
Know the importance of effective communication in the family
Practice effective listening, positive communication and assertive
communication with their family members
Know the importance and guidelines of holding family meetings
Listening to the participant’s experience of drug use
Be able to express to family members the impact of drug use to the self
and to family life
Reflect on the relationship between drug use and family dynamics
Describe their vision for themselves
Describe their vision for their family
Discuss what kind of support and help is needed for their effective
recovery from drugs
Plan as a family about concrete steps to reach their goals
Write a contract that contains concrete tasks and plans for each family
member

Measures
The study used standardized measures that were culturally adapted. Scales underwent
forward and back translation and were pilot-tested.
䊏 Recovery sskills. selected items from Litman, Stapleton, Oppenheim and Peleg’s
coping behaviors inventory (Litman et al., 1984) were used to measure recovery skills of
drug users. Participants rated 17 items using a four-point forced Likert scale (0 = never;
3 = always). Sample items include, “staying away from people who use drugs,” and
“joining groups that help people stop using drugs.” Internal consistency (Cronbach’s a)
was 0.92 (pre-test) and 0.93(post-test).
䊏 Life Skills. adapted from Sharma’s (2003) life skills questionnaire, selected items were
used to measure the life skills taught in the program. A total of 15 items measured skills

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 related to relational, interpersonal, decision-making, problem-solving, coping with
stress and coping with emotions. Sample items include, “I can seek support from
others” and “I can make decisions about important life plans,” participants were asked
the extent to which they agree with the statements using a five-point Likert scale (1 =
strongly disagree; 5 = strongly agree). Internal consistency (Cronbach’s a) was 0.86
(pretest) and 0.91 (post-test).
䊏 Substance use dependence symptoms was based on the World Health Organization’s
(2016) International Classification of Diseases – 10th edition (ICD-10). It was measured
using the ICD-10 checklist for mental disorders (psychoactive substance use) that asks
participants to indicate whether or not they experience symptoms such as cravings,
withdrawal and harmful effects. Internal consistency reliability was 0.77 (pre-test) and
0.72 (post-test).

Procedures
Researchers partnered with two cities in Metro Manila. In one city, the program was given to
prisoners prior to their release (TWI), while in the other city, it was part of their post-release
recovery drug program – plea bargainers went through the intervention once they were
released to the community (OP). The control group (WC) also came from the same city as
the OP group.
For both OP and TWI, anti-drug abuse personnel tasked to facilitate community-based
intervention programs, underwent the KKDK intensive facilitator’s training. Meanwhile,
church volunteers, who also underwent the same training, also served as facilitators for the
OP group. The staff and volunteers or community facilitators received coaching sessions
from site coordinators after each facilitation. Site coordinators observed and monitored the
progress of community facilitators and the program during the duration of its
implementation
Two TWI groups participated in the pre-release program; one group from a female city jail
and another from a male city jail, who attended the program on different separate days.
Once a week, each TWI group received back-to-back sessions in a center outside the
prison. The prisoners received meals during their breaks. After receiving two sessions, the
participants travelled back to their respective jails.
The OP group, on the other hand, were released into the community from a range of one
week to four weeks prior to receiving the program. Once released, they had to report to the
city anti-drug abuse office and complete the community-based drug recovery program as
part of their plea-bargaining arrangement. There were five pods or implementation sites
located in various areas of the city to accommodate the plea bargainers in all the
barangays. Each pod had 10–15 plea-bargainers who attended the KKDK Intensive
program twice a week, one session a day, for a total of 22–24 weeks. A coordinator was
assigned to administer the surveys and coach facilitators.

Data analysis
To analyze the pre- and post-test scores, intent-to-treat was applied to the current study,
which requires all participants to be included in the analyzes regardless of attrition (Gupta,
2011). A multilevel model (MLM; Hoffman, 2015) analogue to a 2 (baseline vs follow-up)  3
(WC vs OP vs TWI) repeated-measures analysis of variance (ANOVA) was used to account
for missing values [using full-information maximum likelihood (FIML) rather than listwise
deletion] and to account for excessive zeroes for the SUD symptoms (using Poisson
distribution; see also Results). For MLM analyzes, group conditions were dummy coded,
with the WC group treated as the reference group. The MLM is represented by the following
equation:

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 yti ¼ b0 þ b1 ðtime Þ þ b2 ðOP Þ þ b3 ðTWI Þ þ b4 ðtime  OP Þ þ b5 ðtime  TWI Þ þ U0i þ eti

where b0 is the expected mean of the WC (reference) group at baseline; b1 is the slope or
mean change from baseline to follow-up for the WC group; b2 is the mean difference between
the OP and WC group at baseline; b3 is the mean difference between the TWI and WC
condition at baseline; b4 is the difference in slope between the OP and WC group; and b5 is
the difference in slope between the TWI and WC group. U0i and eti represents the random
intercept variance and residual variance, respectively. Given these parameters, we can
compute the model predicted mean and mean difference at baseline and follow-up for each
group, and the slope change for each group (Table 3). MLM analyzes were performed using
MPlus v8 (Muthén and Muthén, 1998/2017) using maximum likelihood procedures. The SUD
symptom distribution was highly skewed with a large proportion of 0. To account for this, a
generalized MLM was used, specifically using a Poisson distribution (Coxe et al., 2009).

Ethical considerations
Ethical approval to conduct the study was obtained from the Ateneo de Manila University.
The information collected was coded to maintain the privacy and confidentiality of
participants. Only the researchers had access to individual data.

Results
Descriptive statistics
Table 2 presents the demographic and descriptive statistics. Significant demographic
differences were found for gender and age of first use. Specifically, the TWI had significantly
more females compared to the other conditions. Also, post hoc analysis indicated that the TWI
group, on average, had a much later drug use initiation compared to the WC condition.
Regarding attrition, 72% of the WC group left the study at follow-up, which we accounted for
through FIML. Looking at group differences at baseline, participants in the WC who remained
in the study (m = 1.65, SD = 2.17) had significantly higher SUD scores compared to those who

Table 2 Demographic and descriptive statistics, attrition and missingness

WC OP TWI
n = 121 n = 50 n = 63
Group m/n SD/% m/n SD/% m/n SD/% x2 F

Gender (males) 109 90 45 90 32 51 44.20
Age 35.21 8.98 36.83 10.27 38.6 9.84 2.70

Age of first use 24.22 8.11 25.46 11.21 29.85 10.13 7.39
Years drug use 11.28 8.84 11.83 7.73 8.87 8.95 1.97
Attrition and missingness

Complete baseline and follow-up 34 28 36 72 63 100 147.73
Missing baseline only 0 0 10 20 0 0
Missing follow-up only 87 72 4 8 0 0
Drug recovery skills
Baseline 25.24 12.39 29.8 12.93 33.3 11.49
Follow-up 27.71 12.54 35.03 13.68 40.57 9.94
Life skills
Baseline 62.14 5.99 60.7 6.49 62.05 7.39
Follow-up 62.2 6.8 64.4 6.56 67.93 5.96
SUD symptoms
Baseline 1.07 1.03 1 1.81 0.4 1.01
Follow-up 1.62 1.6 0.63 1.03 0.25 0.80
Note:  p < 0.01; OP = outpatient; WC = wait control; TWI = treatment while incarceration

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left at follow-up (m = 0.84, SD = 1.29; t = 2.03, p = 0.048). No significant differences were noted
for coping (t = –0.43, p = 0.67) and life skills (t = –1.38, p = 0.17).
Examination of SUD symptom scores through univariate statistics indicated a highly skewed
distribution with a large proportion of 0. Overall, the count proportion of 0 was 68% for the
entire data set. For the WC group, 54% and 17% scored 0 at baseline and follow-
up, respectively. For the OP group, 54% and 42% scored 0 at baseline and follow-
up, respectively. For the TWI group, 83% and 89% scored 0 at baseline and follow-up,
respectively. This indicates that majority would be classified as low-risk users.

Impact of intervention
Multilevel modeling was conducted to test for the impact of the intervention. Table 3
presents the parameters for the model in respect of the means and the variance, model
predicted means and mean differences and slope for each condition. For recovery skills,
the OP and TWI group had significantly higher scores compared to the WC group at
baseline (Table 3, model predicted mean difference). However, no significant difference
was observed between OP and TWI at baseline.
A significant increase was observed for the OP and TWI, whereas there was no significant
change in recovery skills for the WC (Table 3, slope). This indicates that participants of the

Table 3 Results of the MLM analysis: model for the means and variance, model predicted
means and mean difference and slopes
Treatment outcomes Drug recovery skills Life skills SUD symptomsa

Model for the means

b0 Intercept 25.23 62.14 –0.70
b1 Time 2.40 0.70 –0.36
b2 OP 4.29 –1.21 –0.37
b3 TWI 8.06 –0.09 –1.24
b4 Time OP 2.81 2.95 0.09
b5 Time TWI 4.89 5.07 –0.10
Model for the variance
eti Residual variance 67.71 21.56
U0i Random intercept variance 75.41 18.97 1.99
Model predicted cell means
b0 Mean for WC at baseline 25.23 62.14 –0.70
b0 þ b2 Mean for OP at baseline 29.52 60.93 –1.07
b0 þ b3 Mean for TWI at baseline 33.29 62.05 –1.95
b0 þ b1 Mean for WC at follow-up 27.63 62.84 –1.06
b0 þ b1 þ b2 þ b4 Mean for OP at follow-up 34.72 64.59 –1.34
b0 þ b1 þ b3 þ b5 Mean for TWI at follow-up 40.58 67.82 –2.40
Model predicted mean difference
b2 OP vs WC at baseline 4.29 –1.21 –0.37
b3 TWI vs WC at baseline 8.06 –0.09 –1.24
b3 – b2 TWI vs OP at baseline 3.77 1.12 –0.88
(b2 þ b4) – (b0 þ b1) OP vs WC at follow-up 7.09 1.75 –0.28
(b3 þ b5) – (b0 þ b1) TWI vs WC at follow-up 12.95 4.98 –1.34
(b3 þ b5) – (b2 þ b4) TWI vs OP at follow-up 5.86 3.23 –1.06
Slope
b1 WC Slope 2.40 0.70 –0.36
b1 þ b4 OP Slope 5.20 3.65 –0.27
b1 þ b5 TWI Slope 7.29 5.77 –0.46

Notes:  p < 0.05;  p < 0.01. WC = Waitlist-control group; OP = Outpatient group; TWI = Treatment-
while-incarcerated group; SUD = Substance use disorder

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 intervention significantly improved their recovery skills compared to those who did not
receive the intervention.
No significant difference was observed among the WC, OP and TWI group in life skills at
baseline. No significant change in life skills scores were observed for the WC, whereas a
significant increase was observed for the OP and TWI. This suggests that those who
underwent the intervention had improved their life skills compared to those who did not go
through the intervention.
A generalized MLM (using Poisson distribution) was used for the SUD because of the highly
skewed distribution and high proportion of zeroes in the data. Results indicate that at
baseline, the TWI had a significantly lower number of SUD symptoms compared to the WC
group (b3). Although there was a decrease in SUD symptoms in all groups, these changes
were not statistically significant for all groups.

Differences between treatment-while-incarcerated and outpatient groups

We hypothesized that because of the likelihood of attrition and inconsistency of attendance,
clients who received TWI would have better outcomes than those in the outpatient
programs. There were no significant differences in outcomes of those in the pre-release and
post-release programs for recovery skills, life skills and SUD symptoms. However, data
revealed that the slope difference between the WC and OP were more similar than that of
the TWI for both recovery and life skills.

Discussion
The study hypothesized that the treatment would improve the drug recovery skills of
participants compared to non-participants. Results showed significant differences in both
OP participants and those who received TWI as compared to the WC whose recovery skills
did not change significantly.
An interesting finding is that participants in both OP and TWI had higher drug recovery skills
compared to those in the WC group even during baseline. One explanation for this is
motivation. Although all respondents applied for plea bargaining, those who were in
treatment already had release papers (OP) or had release papers in process (TWI). One
condition of plea bargaining is that they undergo regular drug-testing and if they are tested
positive for drug-use, their papers can be revoked by the court. Thus, compared to the WC
group, the TWI and OP had greater motivation to refrain from drug use. The results support
the use of CBT (Prendergast et al., 2017) and MI to address substance use and other risk-
taking behaviors (Stein et al., 2002).
Support was found for the hypothesis that participants who attended the program will have
improved life skills compared to non-participants. No significant differences were observed
among the WC, OP and TWI groups at baseline. However, pre-test and post-test scores for
life skills revealed significant changes for OP and TWI groups but no significant change for
those in WC group. The results support the value of developing adaptive coping skills to
reduce cravings, manage triggers and prevent relapse (Skewes and Gonzalez, 2013). It
also highlights the importance of life skills helping people better manage their difficult
emotions, cope with negative life circumstances, enhance social support for sobriety and
establish a lifestyle free of substance use, which is critical to long-term recovery (Skewes
and Gonzalez, 2013).
There was no support for the hypothesis that participants who received treatment will have
significant changes in SUD symptoms compared to those in the WC group. Baseline scores
reveal that the TWI had a significantly lower number of SUD symptoms compared to the WC
group (b3). Although scores for SUD symptoms increased between pre- and post-tests for
WC and decreased for OP and TWI, the changes were not statistically significant. One

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explanation for this was that skewed nature of the data because users tend to be mild-risk
and many had scores of 0 to begin with.
Finally, contrary to hypothesis, there were no significant differences in outcomes of those in the
treatment while incarceration and outpatient programs for recovery skills, life skills and SUD
symptoms. However, the two groups did significantly differ in terms of attrition. TWI had 100%
complete data, whereas only 72% of the OP group were able to complete treatment. However,
the lower retention rate for the OP is not too different from the experience in other countries that
report even lower retention rates ranging from 30%– 56% (Chaudhry et al., 2012).
The slope of the OP group was more similar to that of the WC group compared to the TWI.
One possible explanation for this was that the OP group were already facing “real world”
challenges that were not yet being experienced by the TWI group. Hence, their evaluation
of their ability to manage their cravings, triggers and life skills may be more realistic
compared to those in the TWI groups.

Limitations and implications for research

A major limitation of the study was because of legal issues, the study used a quasi-experimental
research design rather than a randomized control trial design. In addition, the implementation of
treatment for the TWI group was different (two back to back sessions, once a week) compared to
that of the OP program (one session, twice a week). Another limitation was that the WC sample
only came from the OP site and not the TWI site. Researchers also had no control over the high
attrition of the WC because some prisoners were already released during the post-test. Future
research using randomized controlled trials are important to provide more robust conclusions.
The study design was also limited to a simple pre- and post-test evaluation. Future studies
may wish to look at longitudinal outcomes including recidivism, relapse and reintegration.
Another major limitation was the lack of information on comorbid mental illness. This was not
part of the screening processes of doctors. Obtaining information on co-morbidity would be
important to determine the appropriate treatment for those with mental illness.

Implications for practice

Limitations notwithstanding, the results suggest that the program has promise as a drug
treatment program for Filipinos incarcerated because of drug use. Although significant
changes in both recovery and life skills were observed for both TWI and OP groups, it was
observed that retention was higher when used as a pre-release program. Given this, it may
be more advantageous to deliver treatment to prisoners while they are incarcerated as
preparation for reintegration. However, it is also important that aftercare programs are
provided upon release to facilitate the reintegration of those who were incarcerated.
However, the research team also noted common challenges in program implementation such as
the lack of personnel, resources and space. For the TWI, a major barrier was the lack of space
to conduct sessions. Prisoners had to be transported to treatment site requiring the transport of
prisoners and additional security personnel. We also noted the importance of meals in the
delivery of the program. Given the inadequate nutrition in prison, participants were often hungry
and researchers had to ensure they were given full meals prior to the session. This lack of
resources has also been reported in studies in other countries (Amodeo et al., 2011).
Another critical challenge was the lack of trained personnel. Most facilitators were not
professional addiction personnel and were not accustomed to handling prisoners. Studies
examining the impact of a program when delivered by prison welfare personnel vis-à-vis
community facilitators would be useful to determine if the effect of treatment would be different
if the program is delivered by health professionals. In addition, the data suggests the need to
provide supervision and coaching to facilitators. The lack of staff training has also been
reported in community-based interventions in other countries (Amodeo et al., 2011).

j INTERNATIONAL JOURNAL OF PRISONER HEALTH j

 Despite the limitations of the study, the results suggest that psychosocial treatments for
incarcerated drug users have the potential to build drug recovery and life skills. Moreover,
the inclusion of family modules also highlights the importance of harnessing family support
as a recovery capital for prisoners incarcerated because of drug use.
However, the results also suggest that in developing economies such as the Philippines,
psychosocial treatments for incarcerated drug users require greater investment in
resources. However, there is evidence that a lack of resources, especially in terms of
housing and employment, for the reintegration of rehabilitated drug users are common
problems even in developed countries such as the USA (Amodeo et al., 2011).

Conclusions
This study examined a psychosocial intervention that aimed to develop the recovery skills, life
skills and family support of persons incarcerated because of drug use. The quasi-experimental
study tested a treatment program given to prisoners while incarcerated and as an outpatient
program for those released from prison compared to a WC group who did not receive the
intervention. Findings revealed improvements in recovery and life skills for those who received
the intervention as compared to those who did not. There was no significant differences
between those who received the program while incarcerated and those who received it as
outpatients, suggesting that the program can be used for both. However, attrition was higher
among those in the outpatient program. Although there was a decrease in SUD symptoms for all
groups, the decrease was not significantly different possibly because two-thirds of participants
had scores of 0 to begin with. The study had limitations in terms of the lack of randomization in
design, the lack of objective measures of drug use and the lack of longitudinal data.
Nevertheless, the initial results suggest that psychosocial interventions may be valuable in
providing skills and support to prisoners who use drugs thus enabling their recovery.

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Corresponding author
Ma. Regina M. Hechanova can be contacted at: rhechanova@ateneo.edu

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