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Program Profile: Delaware KEY/Crest Substance Abuse Programs

Evidence Rating: Promising - One study Promising - One study

Date: This profile was posted on June 07, 2011

Program Summary

A prison-based therapeutic community for offenders with a history of substance abuse and a residential work release center that allows offenders to continue their treatment as they transition to the community. The program is rated Promising. Program completers and aftercare recipients were less likely to be arrested or use drugs. Also, the treatment group did better at follow-up in remaining arrest and drug-free.

Program Description

Program Goals, Target Population
KEY/Crest is a corrections- and community-based multistage substance abuse treatment program for drug-involved offenders. The Delaware Department of Correction (DOC) provides a continuum of primary (in prison), secondary (work release), and tertiary (aftercare) therapeutic community (TC) treatment for drug-involved offenders. Each stage in the continuum corresponds to the offender’s changing correctional status: incarceration, work release, and parole or community supervision.

Services Provided, Program Theory
KEY is the first component of the substance abuse treatment continuum. The prison-based TC program is designed as a total treatment environment and is discipline-based and isolated from the rest of the prison population. The treatment perspective of the KEY program is that drug abuse is a disorder; addiction is the symptom, not the essence of the disorder. Therefore, the primary goal of KEY is to change negative patterns of behavior, thinking, and feelings that predispose an offender toward drug abuse. Inmates receive behavioral, cognitive, and emotional therapy that focuses on changing behavior first and emotion last.

Inmates typically become involved in the KEY program during the last 12 to 18 months of incarceration. Inmates are provided with a routine that is disciplined and regimented, and are required to complete program assignments which are seen as essential to treatment. KEY staff members provide oversight to treatment programming, which is scheduled 7 days a week. Inmates have daily access to staff counselors if they feel the need to discuss issues related to their treatment and recovery. Inmates also meet twice a week with their caseload group (other inmate program participants) to discuss issues related to recovery.

The second component of the substance abuse program is Crest. The Crest Outreach Centers are residential work release centers based on the TC model that allow offenders recovering from substance abuse to continue their treatment as they transition into the community.

Typically, offenders work during the day and return to their assigned center at night for therapy, counseling, or treatment. The Crest program is usually 6 months in duration. The first 3 are spent entirely at the Crest Center, with offenders engaged in full-time substance abuse treatment. During the next 3 months, offenders become involved in the work-release portion of the program. Offenders go through several phases of treatment during their time in the Crest program:
  • Entry, evaluation, and orientation: Offenders get used to life outside of prison.
  • Primary: Counselors and offenders explore the challenges and issues faced by individual offenders and prepare appropriate responses to minimize the likelihood of relapse.
  • Job-seeking: Offenders develop job-seeking and interviewing skills.
  • Work Release: Offenders maintain residence at Crest while working in the community.
Aftercare is the final component of the substance abuse treatment continuum and takes place once an offender has completed Crest and is on probation. Offenders taking part in aftercare are living full-time in the community and return weekly to an assigned center for group sessions and counseling. Offenders also participate in random, mandatory drug testing.

Evaluation Outcomes

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Study 1

The analyses by Martin, Butzin, and Inciardi (1995) showed that the KEY–Crest and Crest–only groups were significantly more likely to be drug-free and arrest-free at follow-up than the KEY–only and the no-treatment groups. The differences between the KEY–only group and the comparison group on both measures were not statistically significant, however.


Drug Use and Arrest Status

To account for differences between the study groups that may affect measures of drug use and arrest, a second analysis controlled for other predictors of arrest and drug use, such as criminal history, prior drug use, and time in treatment. The outcome measures for drug use and arrest showed that participating in KEY–Crest and Crest still resulted in significantly better outcomes relative to the comparison group. However, for both outcome measures, the KEY group was not statistically different from the comparison group. The results suggest that TC treatment without a transitional work release or aftercare component is not as effective.


HIV Index

The rate of injection drug use was significantly reduced for the Crest–only group. Although the rate of injection drug use was also substantially reduced for the KEY–Crest group, the effect was not statistically significant. There was no apparent benefit for the KEY–only group.


For condom use, both the KEY–only and KEY–Crest groups showed a significantly higher use. The Crest–only group showed a higher use rate then the comparison group, but it was not statistically significant.


Study 2

Drug Use and Arrest Status, Original Grouping

When looking at the original four study groups (KEY–only, KEY–Crest, Crest–only, and the comparison group), Martin and colleagues (1999) found that the KEY group was not significantly different from the comparison group in measures of arrest-free and drug-free status. For arrest-free status, there is a small but insignificant benefit of TC treatment versus the comparison group, but there were no differences among the three TC groups. For drug-free status, TC treatment in each of the three groups does produce a significant increase in the probability of being drug-free, as opposed to the comparison group. However, among the TC groups, there are no differences in the likelihood of being drug-free. The results would suggest there are modest benefits for some TC treatment as compared to no TC treatment, but there’s no indication that the probability of remaining drug-free and arrest-free increases with more stages of TC treatment. This is in contrast to results from the previous study, which found TC treatment with work release and aftercare components to be more beneficial to program participants than just TC treatment.


Drug Use and Arrest Status, New Grouping

When looking at the new grouping of study participants (Crest dropouts, Crest graduates with aftercare, and Crest graduates without aftercare), the results are somewhat different. Crest dropouts are just as likely to be arrested on a new charge as the comparison group. However, those who complete Crest do much better, and those who complete Crest and receive aftercare are the least likely to have a new arrest. For drug-free status, Crest dropouts are more than three times as likely to be drug-free, Crest completers more than five times as likely, and Crest completers with aftercare are seven times more likely to be drug-free versus the comparison group.


Study 3

Drug Use and Arrest Status at 42 Months

Inciardi, Martin, and Butzin (2004) found that participation in the transitional treatment program more than quadrupled the odds of remaining drug-free at 42 months. Treatment participation was also a significant predictor of criminal recidivism. There was a 70 percent reduction in the odds of a new arrest for those assigned to treatment.


Drug Use and Arrest Status at 60 Months

The results for drug use and rearrests at 60 months were similar to the results at 42 months. Participation in the transitional treatment program still more than tripled the odds of remaining drug-free. Additionally, study participants with no previous treatment were more likely to relapse, while those who received treatment were significant less likely to relapse. Treatment participation was also a significant predictor of no new arrests at 60 months.


Drug Use and Arrest Status, All Treatment Group

A second analysis broke out the All Treatment Group into three separate groups: dropouts, graduates without aftercare, and graduates with aftercare, and compared the outcomes to the control group that did not receive treatment. The results showed consistent effects through the follow-up periods. Study participants who completed TC treatment with or without aftercare had significantly greater probabilities of remaining both arrest-free and drug-free at both time points than did those without treatment. Those program participants who did complete treatment and attended aftercare were the least likely to have a new arrest or to have relapsed into drug use. Just under half of those who completed treatment and then attended aftercare would be expected to have a new arrest, compared to more than 75 percent of the group without treatment. Those in the treated groups were 15 to 20 times more likely to be drug-free compared to the group without treatment.

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Evaluation Methodology

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Study 1
The first study, by Martin, Butzin, and Inciardi (1995), used a quasi-experimental design to examine the differences among 457 subjects who participated in the following conditions:
  • Primary treatment in prison at KEY program with no subsequent treatment (KEY group, n=43)
  • Primary treatment in prison at KEY program and secondary (transitional) treatment at Crest Outreach Center (KEY–Crest group, n=32)
  • Primary treatment at Crest with no prior prison-based treatment (Crest, n=176)
  • No treatment other than HIV/AIDS prevention education (comparison, n=206)
Subjects in the KEY and KEY–Crest group were not randomly assigned; offenders are assigned to treatment by prison personnel who determine eligibility based on institutional classification screening. Offenders that were assigned to work release after prison and had a history of chronic, heavy drug use but who had not participated in the prison TC, however, were randomly assigned to either the Crest group or the comparison group.

The sample was mostly male (81 percent) and African American (72 percent), with the remaining mostly white. There were a few significant differences between the groups. The KEY and KEY–Crest groups had more African American participants as well as more participants who, on average, had longer criminal histories. Also, all of the KEY and KEY–Crest subjects were male, as there was no TC available for female inmates at the time. There were no statistically significant differences between the treatment groups and comparison group on baseline characteristics.

Subjects were interviewed just prior to leaving prison and again about 6 months after release. Self-reported measures were also collected on sexual activities, criminal history, drug abuse treatment history, psychosocial and mental health status, and sociodemographics. The two primary outcome measures of interest were arrest status and drug use. Arrest status was based on whether respondents reported any arrests since release from prison. Drug use was based on a composite of questions asking about the frequency of use of injecting or noninjecting cocaine, heroin and speed, crack, phencyclidine (or PCP), hallucinogens, and opioids. Two additional outcome measures were intended as a rough index of risk of HIV infection: the use of any injection drugs since release and report of condom use. The primary mode of statistical analysis was logistic regression, with additional chi-square analyses.

Study 2
A follow-up study by Martin and colleagues (1999) looked at the outcome results 1 year and 3 years after leaving work release. The study examined the same four groups as the previous study by Martin, Butzin, and Inciardi, in addition to a different four-group comparison:
  • Study participants who received no in-prison treatment, assigned to regular work release (comparison, n=210)
  • Crest dropouts (n=109)
  • Crest graduates without aftercare (n=101)
  • Crest graduates with aftercare (n=69)
This grouping allowed the authors to distinguish between the major elements of the TC continuum, particularly in the secondary (work release) and tertiary (aftercare) stages that had not been studied previously. Also, the KEY–only group from the previous study was excluded because by the time of this study almost all KEY graduates were being assigned to Crest for their work release assignment. The new grouping also combines KEY graduates who additionally went to Crest, together with those who received their primary treatment at Crest and did not attend KEY.

The entire sample was predominately male (79 percent), and 73 percent African American, 23 percent white, and 3 percent Hispanic. Average age of the participants was about 30 years.

The outcome measures of interest were relapse (drug-free) and recidivism (arrest-free). Each outcome variable combines information from repeated self-report and official data. To be considered drug free, the study participant must have reported no illegal drug use and have tested negative for drugs on the urine screen at every follow-up point. Similarly, arrest-free was measured as no self-reports of arrest and no official arrest record for new offenses since release from prison (this does not include parole violations). The study relied on bivariate and multivariate logistic regression to analyze the data.

Study 3
Inciardi, Martin, and Butzin (2004) looked at the outcome results from interviews conducted with study participants at 42 months (3.5 years) and 60 months (5 years) after release from prison. In this study, the groups were divided as follows:
  • All treatment groups (n=472); this included dropouts (n=166), graduates (n=138) and graduates with aftercare (n=168)
  • No Treatment Group (n=218)
The study participants in the All Treatment Groups category were 76 percent male and 75 percent African American, with an average age of 30.4 years. The No Treatment Group was 82 percent male and 68 percent African American, with an average age of 29.6 years. There were no significant differences between the treatment groups and the no-treatment group.

Similar to the previous studies, the analyses examined two main measures, relapse to illegal drug use and rearrest through the follow-up periods. As in the previous study by Martin and colleagues (1999), to be considered drug-free, the study participant must have reported no illegal drug use and tested negative for drugs on the urine screen at every follow-up point. Similarly, arrest-free was measured as no self-reports of arrest and no official arrest record for new offenses since release from prison. The data was analyzed using multivariate logistic regression with treatment status, gender, race, age, criminal history, and history of drug use and treatment as predictors of relapse and recidivism.
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There is no cost information available for this program.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Martin, Steven S., Clifford A. Butzin, and James A. Inciardi. 1995. “Assessment of a Multistage Therapeutic Community for Drug-Involved Offenders.” Journal of Psychoactive Drugs 27(1):109–16.

Study 2
Martin, Steven S., Clifford A. Butzin, Christine A. Saum, and James A. Inciardi. 1999. “Three-Year Outcomes of Therapeutic Community Treatment for Drug-Involved Offenders in Delaware: From Prison to Work Release to Aftercare.” The Prison Journal 79(3):294–320.

Study 3
Inciardi, James A., Steven S. Martin, and Clifford A. Butzin. 2004. “Five-Year Outcomes of Therapeutic Community Treatment of Drug-Involved Offenders After Release From Prison.” Crime & Delinquency 50(1):88–107.
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Additional References

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These sources were used in the development of the program profile:

Falcon, William D. 2002. “Corrections-Based Drug Treatment: Delaware’s Key-Crest Programs.” Promising Approaches to Addressing Crime. Washington, D.C.: The Jerry Lee Center of Criminology, Forum on Crime & Justice. Accessed January 20, 2011.

Martin, Steven S., Daniel J. O’Connell, Raymond Paternoster, and Ronet D. Bachman. 2011. “The Long and Winding Road to Desistance From Crime for Drug-Involved Offenders: The Long-Term Influence of TC Treatment on Rearrest.” Journal of Drug Issues 41(2):179–96.

State of Delaware. 2011. “Treatment Services.” Accessed January 12, 2011.
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Related Practices

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Following are practices that are related to this program:

Incarceration-based Therapeutic Communities for Adults
This practice uses a comprehensive, residential drug treatment program model for treating substance-abusing and addicted inmates to foster changes in attitudes, perceptions, and behaviors related to substance use. The practice is rated Effective in reducing recidivism rates after release for participants in therapeutic communities.

Evidence Ratings for Outcomes:
Effective - More than one Meta-Analysis Crime & Delinquency - Multiple crime/offense types
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Program Snapshot

Age: 18+

Gender: Both

Race/Ethnicity: Black, Hispanic, White, Other

Geography: Suburban, Urban

Setting (Delivery): Correctional, Other Community Setting

Program Type: Alcohol and Drug Therapy/Treatment, Aftercare/Reentry, Group Therapy, Individual Therapy, Residential Treatment Center, Therapeutic Communities

Targeted Population: Alcohol and Other Drug (AOD) Offenders, Prisoners

Current Program Status: Active

Listed by Other Directories: Campbell Collaboration

Program Developer:
Lisa Ritchie
Assistant Program Manager, Substance Abuse
MHM Services, Inc.
300 Water Street
Dover DE 19904
Phone: 301.739.1537
Fax: 302.739.1536

Steven S. Martin
Senior Scientist and Associate Director
Center for Drug & Alcohol Studies, University of Delaware
77 Main Street
Newark DE 19716-2583
Phone: 302.831.6107
Fax: 302.831.3307

Training and TA Provider:
Harry K. Wexler
Investigator Emeritus
National Development and Research Institutes, Inc.
71 W 23rd Street, 8th Floor
New York NY 10010
Phone: 917.562.7273
Fax: 917.562.7273

Training and TA Provider:
Dorothy Lockwood Dillard
Assistant Professor
Delaware State University
1200 North DuPont Highway
Dover DE 19901
Phone: 302.857.7510