After reading the Prison-Based Chemical Dependency Treatment in Minnesota: An Outcome Evaluation and Substance Abuse Treatment for Adults in the Criminal Justice System articles, discuss the following in your initial post: What are the pros and cons of su

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A Treatment Improvement

Protocol

Substance Abuse Treatment For Adults in the Criminal

Justice System

TIP 44

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

CJr CRIMINAL JUSTICE

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment

1 Choke Cherry Road Rockville, MD 20857

Substance Abuse Treatment

For Adults in the Criminal Justice System

A Treatment Improvement

Protocol

TIP 44

Roger H. Peters, Ph.D. Consensus Panel Co-Chair

Harry K. Wexler, Ph.D. Consensus Panel Co-Chair

Acknowledgments Numerous people contributed to the develop- ment of this TIP (see pp. xi–xiv and appendices D, E, F, and G). This publication was pro- duced by The CDM Group, Inc. under the Knowledge Application Program (KAP) con- tract, number 270-99-7072 with the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS). Karl D. White, Ed.D., and Andrea Kopstein, Ph.D., M.P.H., served as the Center for Substance Abuse Treatment (CSAT) Government Project Officers. Christina Currier served as the CSAT TIPs Task Leader. Rose M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC, served as the CDM KAP Executive Deputy Project Director. Elizabeth Marsh served as the CDM KAP Deputy Project Director. Shel Weinberg, Ph.D., served as the CDM KAP Senior Research/Applied Psychologist. Other KAP personnel included Raquel Witkin, M.S., Deputy Project Manager; Susan Kimner, Managing Editor; Deborah Steinbach, M.A., Editor/Writer; Janet Humphrey, M.A., Editor/Writer; Michelle Myers, Quality Assurance Editor; and Elizabeth Plevyak, Editorial Assistant. In addi- tion, Sandra Clunies, M.S., I.C.A.D.C., served as Content Advisor. Catalina Bartlett, M.A., Janet Dinsmore, B.A., J. Max Gilbert, M.A., Annette Kornblum, M.S., Joyce Latham, Helen Oliff, B.A., CEC, Susan Paisner, M.A., and David Sutton, B.A., were writers. Special thanks go to Gary Field, Ph.D., for his consid- erable contribution to this document.

Disclaimer The opinions expressed herein are the views of the Consensus Panel members and do not nec- essarily reflect the official position of CSAT, SAMHSA, or DHHS. No official support of or endorsement by CSAT, SAMHSA, or DHHS for these opinions or for particular instru- ments, software, or resources described in this document are intended or should be inferred.

The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions.

Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be repro- duced or copied without permission from SAMHSA/CSAT or the authors. Do not repro- duce or distribute this publication for a fee without specific, written authorization from SAMHSA’s Office of Communications.

Electronic Access and Copies of Publication Copies may be obtained free of charge from SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729- 6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889, or electronically through the following World Wide Web site: www.samhsa.gov/centers/csat/csat.html.

Recommended Citation Center for Substance Abuse Treatment. Substance Abuse Treatment for Adults in the Criminal Justice System. Treatment Improvement Protocol (TIP) Series 44. DHHS Publication No. (SMA) 05-4056. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

Originating Office Practice Improvement Branch, Division of Services Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857.

DHHS Publication No. (SMA) 05-4056 Printed 2005

ii Acknowledgments

Contents

What Is a TIP? ........................................................................................................ix

Consensus Panel ......................................................................................................xi

KAP Expert Panel and Federal Government Participants ..............................................xiii

Foreword ...............................................................................................................xv

Executive Summary ...............................................................................................xvii

Chapter 1—Introduction ............................................................................................1 Overview..................................................................................................................1 The Purpose of This TIP .............................................................................................3 Key Definitions ..........................................................................................................4 Audience for This TIP.................................................................................................5 Contents of This TIP...................................................................................................5

Chapter 2—Screening and Assessment ..........................................................................7 Overview..................................................................................................................7 Definitions of Terms....................................................................................................7 Screening Guidelines ...................................................................................................9 Assessment Guidelines................................................................................................10 Key Issues Related to Screening and Assessment...............................................................13 Areas To Address in Screening and Assessment ................................................................18 Selection and Implementation of Instruments ..................................................................33 Screening and Assessment Considerations for Specific Populations .......................................36 Integrated Screening and Assessment—Sample Approaches ................................................39 Conclusions and Recommendations ...............................................................................40

Chapter 3—Triage and Placement in Treatment Services ...............................................43 Overview ................................................................................................................43 Treatment Levels and Components................................................................................43 Potential Barriers to Triage and Placement .....................................................................47 Creating a Triage and Placement System ........................................................................47 Compiling Information To Guide Triage and Placement Decisions.........................................49 Conclusions and Recommendations ...............................................................................56

Chapter 4—Substance Abuse Treatment Planning .........................................................59 Overview ................................................................................................................59 Assessing the Severity of Substance Use Disorders ............................................................60 Assessing the Severity of Co-Occurring Disorders .............................................................60 Criminality and Psychopathy ......................................................................................63 Client Motivation and Readiness for Change ...................................................................65 Implementing an Effective Treatment Planning Process .....................................................67 Conclusions and Recommendations ...............................................................................70

Chapter 5—Major Treatment Issues and Approaches .....................................................71 Overview ................................................................................................................71 Clinical Strategies .....................................................................................................72

iii

iv

Program Components and Strategies .............................................................................84 Conclusions and Recommendations ...............................................................................90

Chapter 6—Adapting Offender Treatment for Specific Populations ..................................93 Overview ................................................................................................................93 Treatment Issues Related to Cultural Minorities ...............................................................93 Women’s Treatment Issues ..........................................................................................95 Men’s Treatment Issues.............................................................................................101 Working With Violent Offenders .................................................................................102 Treatment Issues Based on Client’s Sexual Orientation .....................................................104 Treatment Issues Based on the Client’s Cognitive/Learning, Physical, and Sensory Disabilities ..105 Treatment Issues for Older Adults ...............................................................................107 Treatment Issues for Clients From Rural Areas ..............................................................107 Treatment Issues for People With Co-Occurring Substance Use and Mental Disorders .............108 People With Infectious Diseases ..................................................................................116 Sex Offenders.........................................................................................................119 Conclusions and Recommendations .............................................................................122

Chapter 7—Treatment Issues in Pretrial and Diversion Settings.....................................125 Overview...............................................................................................................125 Introduction ..........................................................................................................125 Characteristics of the Population ................................................................................126 Treatment Services in the Pretrial Justice System ...........................................................127 Trial and Postverdict Periods.....................................................................................130 Diversion to Treatment .............................................................................................131 What Treatment Services Can Reasonably Be Provided in the Pretrial Setting?......................138 Treatment Issues .....................................................................................................143 Developing Pretrial Treatment Services ........................................................................146 Resources..............................................................................................................151 Conclusions and Recommendations .............................................................................154

Chapter 8—Treatment Issues Specific to Jails.............................................................157 Overview...............................................................................................................157 Definitions.............................................................................................................157 Trends ..................................................................................................................158 Treatment Services in Jails ........................................................................................159 Description of the Population.....................................................................................159 Key Issues Related to Treatment .................................................................................163 What Treatment Services Can Reasonably Be Provided in a Jail Setting?..............................166 Coordination of Jail Treatment Services .......................................................................175 Examples of Jail Treatment Programs ..........................................................................183 Research Related to Jail Treatment .............................................................................184 Recommendations for Treatment Providers ...................................................................185

Chapter 9—Treatment Issues Specific to Prisons ........................................................187

Overview...............................................................................................................187 Description of the Population.....................................................................................187 Treatment Services in Prisons ....................................................................................190

Contents

v

Key Issues Affecting Treatment in Prison Settings ...........................................................190 What Treatment Services Can Reasonably Be Provided in the Prison Setting? .......................194 In-Prison Therapeutic Communities ............................................................................199 Specific Populations in Prisons...................................................................................204 Systems Issues ........................................................................................................207 Recommendations and Further Research ......................................................................210

Chapter 10—Treatment for Offenders Under Community Supervision ............................213 Overview...............................................................................................................213 The Population.......................................................................................................214 Levels of Supervision ...............................................................................................214 Treatment Levels and Treatment Components ................................................................214 What Treatment Services Can Reasonably Be Provided for People Under

Community Supervision? .......................................................................................218 Treatment Issues for People Under Community Supervision ..............................................220 Treatment Issues Specific to People on Parole ................................................................226 Treatment Issues Specific to Probationers .....................................................................229 Strategies for Improving System Collaboration ...............................................................229 Sample Programs ....................................................................................................231 Conclusions and Recommendations .............................................................................233

Chapter 11—Key Issues Related to Program Development...........................................235 Overview...............................................................................................................235 Reconciling Public Safety and Public Health Interests .....................................................235 Interdependence of Criminal Justice and Treatment Systems .............................................236 Program-Level Coordination......................................................................................242 Research and Evaluation ..........................................................................................247 Cost Issues.............................................................................................................251 Key Goals of SAMHSA .............................................................................................252 Conclusions ...........................................................................................................252

Appendix A: Bibliography ......................................................................................255

Appendix B: Glossary ...........................................................................................291

Appendix C: Screening and Assessment Instruments ...................................................303

Appendix D: Resource Panel...................................................................................309

Appendix E: Cultural Competency and Diversity Network Participants ...........................313

Appendix F: Special Consultants ..............................................................................315

Appendix G: Field Reviewers...................................................................................317

Index ..................................................................................................................321

CSAT TIPs and Publications....................................................................................335

Figures Figure 2-1. Screening Guidelines by Domain....................................................................11 Figure 2-2. Screening Guidelines by Setting.....................................................................12 Figure 2-3. Recommended Substance Abuse Screening Instruments ......................................19 Figure 2-4. Instruments for Evaluating Readiness for Treatment ..........................................23 Figure 2-5. Instruments for Screening and Assessing Mental Disorders ..................................25 Figure 2-6. Instruments Examining Psychopathy and Risk for Violence and Recidivism .............32

Contents

Figure 3-1. Placement and Triage Strategies ....................................................................50 Figure 4-1. Client’s Recovery Plan (CRP) .......................................................................68 Figure 5-1. Common Thinking Errors ............................................................................75 Figure 5-2. Strategies for Working With Offenders Based on Their Stage in Recovery ...............84 Figure 6-1. Traits of ASPD (DSM-IV) ...........................................................................113 Figure 6-2. Borderline Personality Disorder ..................................................................114 Figure 7-1. Substance Abuse Treatment Planning Chart for Treatment-Based Drug Courts .......134 Figure 8-1. Treatment Components ..............................................................................168 Figure 8-2. Goals of the Treatment and Corrections System in the Jail Setting........................176 Figure 8-3. Targeted Treatment for Special Populations Versus Mainstream Treatment for

Larger Populations ..................................................................................178 Figure 8-4. Varied Opinions Regarding Medication Use for Inmates in Jail Treatment Programs 180 Figure 9-1. Reasons for Limitations to Providing Treatment to Prison Inmates.......................191 Figure 9-2. Guidelines for Substance Abuse Treatment in Correctional Facilities ....................192 Figure 9-3. Stay’n Out Program Outcomes ....................................................................202 Figure 10-1. Comparison of Probationers and Parolees ....................................................215 Figure 10-2. Paradigm of Collaboration ........................................................................230 Figure 11-1. CSAT Criminal Justice Treatment Planning Chart ..........................................238 Figure 11-2. Barriers to Effective Treatment ..................................................................243 Figure 11-3. Outcome Information...............................................................................250 Figure 11-4. Definition of Terms .................................................................................251

Advice to the Counselor Boxes Chapter 2 Screening and Assessment ...........................................................................................13 The Need to Rescreen ................................................................................................16 Screening for Detoxification ........................................................................................21 Screening for Co-Occurring Disorders ...........................................................................27 Screening for Trauma ................................................................................................29 Screening for Psychopathy..........................................................................................30 Screening Specific Populations.....................................................................................38

Chapter 3 Triage and Placement ................................................................................................49

Chapter 4 Mental Health Issues .................................................................................................61 Borderline Personality Disorder...................................................................................63 Psychopathy............................................................................................................65 Motivation for Change ...............................................................................................66

Chapter 5 Homelessness ...........................................................................................................73 Criminal Thinking ....................................................................................................74 Family Involvement...................................................................................................78 Addressing the Coerced Client .....................................................................................80 Establishing Boundaries .............................................................................................81 Establishing Counselor Credibility ................................................................................83 Spiritual Approaches .................................................................................................89

vi Contents

Chapter 6 Culture and the Counselor ..........................................................................................95 Treating Female Offenders ..........................................................................................97 Parent Training ......................................................................................................100 Rural Clients, Rural Counselors .................................................................................108 “Good” and “Bad” Drugs..........................................................................................111 Infectious Diseases...................................................................................................118

Chapter 7 General Considerations for Working With Clients in the Criminal Justice System ...................127 Diversion to Treatment Decision Points ........................................................................128 Information Management During the Pretrial Stage .........................................................130 Operating in a Pretrial Setting....................................................................................143 Addressing the Client’s Immediate Needs ......................................................................144

Chapter 8 Jailed Clients .........................................................................................................165 Cross-Training........................................................................................................179

Chapter 9 Prison Treatment Approaches ....................................................................................198 Heading Off Noncompliance.......................................................................................209

Chapter 10 Recommended Treatment Services for People Under Community Supervision........................221 Treatment Issues for People Under Community Supervision ..............................................225 Treatment Issues for People on Parole .........................................................................229

Contents vii

What Is a TIP?

Treatment Improvement Protocols (TIPs), developed by the Center for Substance Abuse Treatment (CSAT), part of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (DHHS), are best-practice guidelines for the treatment of substance use disorders. CSAT draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to facilities and indi- viduals across the country. The audience for the TIPs is expanding beyond public and private treatment facilities to include practitioners in mental health, criminal justice, primary care, and other healthcare and social service settings.

CSAT’s Knowledge Application Program (KAP) expert panel, a distin- guished group of experts on substance use disorders and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Drug Abuse Directors to generate topics for the TIPs. Topics are based on the field’s current needs for information and guidance.

After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to be members of a resource panel that recom- mends specific areas of focus as well as resources that should be consid- ered in developing the content for the TIP. These recommendations are communicated to a consensus panel composed of experts on the topic who have been nominated by their peers. This consensus panel participates in a series of discussions. The information and recommendations on which they reach consensus form the foundation of the TIP. The members of each consensus panel represent substance abuse treatment programs, hos- pitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A panel chair (or co- chairs) ensures that the contents of the TIP mirror the results of the group’s collaboration.

A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incor-

ix

x What Is a TIP?

porated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet at www.kap.samhsa.gov. The online TIPs are consistently updated and pro- vide the field with state-of-the-art information.

While each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey “front-line” information quickly but responsi- bly. For this reason, recommendations prof- fered in the TIP are attributed to either Panelists’ clinical experience or the literature. If research supports a particular approach, citations are provided.

This TIP, Substance Abuse Treatment for Adults in the Criminal Justice System, revises and supersedes TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System, TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System, and TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System. The revised TIP provides the current clinical evidence-based guidelines, tools, and resources necessary to help sub- stance abuse counselors treat clients involved with the criminal justice system.

xi

Consensus Panel

Co-Chair Roger H. Peters, Ph.D. Professor Department of Law and Mental Health Florida Mental Health Institute University of South Florida Tampa, Florida

Co-Chair Harry K. Wexler, Ph.D. Senior Principal Investigator National Development and Research

Institute, Inc. New York, New York

Workgroup Leaders Steven R. Belenko, Ph.D. National Center on Addiction and Substance

Abuse Columbia University New York, New York

Nahama Broner, Ph.D. Senior Research Psychologist Center for Crime, Violence and Justice

Research New York, New York

Christopher J. Geiger Vice President/Director of Criminal Justice

Programs Walden House, Inc. San Francisco, California

Kevin Knight, Ph.D. Research Scientist Texas Christian University Fort Worth, Texas

Michael D. Link, M.C.J. Chief Division of Treatment and Planning Ohio Department of Alcohol and Drug

Addiction Services Columbus, Ohio

Henry Jay Richards, Ph.D. Associate Professor University of Washington Seattle, Washington

Sally J. Stevens, Ph.D. Research Professor Social and Behavioral Sciences Southwest Institute for Research on Women University of Arizona Tucson, Arizona

Panelists Elaine Abraham Program Developer/Consultant National Development and Research, Inc. Chula Vista, California

E. Bernard Anderson, Jr., M.S., M.A., NCAC, ICADC, CCS

Regional Administrator Correctional Treatment Florida Addictions and Correctional

Treatment Services, Inc. Tallahassee, Florida

Annabelle Casas-Mendoza, M.A. Family Treatment Drug Court 65th District Court El Paso, Texas

xii

Deion Cash Executive Director Community Treatment & Correction

Center, Inc. Canton, Ohio

Kimberly S. Hee, M.A. Grants Program Specialist Office of the Mayor Criminal Justice Planning Los Angeles, California

Mack Jenkins, B.A. Division Director Adult Court Services Orange County Probation Department Santa Ana, California

Carl G. Leukefeld, D.S.W. Director Center on Drug and Alcohol Research University of Kentucky Lexington, Kentucky

Erik J. Roskes, M.D. Director Forensic Treatment and Correctional Services School of Medicine Springfield Hospital Center Sykesville, Maryland

Consensus Panel

xiii

Barry S. Brown, Ph.D. Adjunct Professor University of North Carolina at Wilmington Carolina Beach, North Carolina

Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, CJS

Professor of Clinical Psychiatry College of Medicine University of Cincinnati Cincinnati, Ohio

Deion Cash Executive Director Community Treatment and Correction

Center, Inc. Canton, Ohio

Debra A. Claymore, M.Ed.Adm. Owner/Chief Executive Officer WC Consulting, LLC Loveland, Colorado

Carlo C. DiClemente, Ph.D. Chair Department of Psychology University of Maryland Baltimore County Baltimore, Maryland

Catherine E. Dube, Ed.D. Independent Consultant Brown University Providence, Rhode Island

Jerry P. Flanzer, D.S.W., LCSW, CAC Chief, Services Division of Clinical and Services Research National Institute on Drug Abuse Bethesda, Maryland

Michael Galer, D.B.A. Chairman of the Graduate School of Business University of Phoenix—Greater Boston

Campus Braintree, Massachusetts

Renata J. Henry, M.Ed. Director Division of Alcoholism, Drug Abuse,

and Mental Health Delaware Department of Health and Social

Services New Castle, Delaware

Joel Hochberg, M.A. President Asher & Partners Los Angeles, California

Jack Hollis, Ph.D. Associate Director Center for Health Research Kaiser Permanente Portland, Oregon

Mary Beth Johnson, M.S.W. Director Addiction Technology Transfer Center University of Missouri—Kansas City Kansas City, Missouri

Eduardo Lopez, B.S. Executive Producer EVS Communications Washington, DC

Holly A. Massett, Ph.D. Academy for Educational Development Washington, DC

KAP Expert Panel and Federal Government Participants

xiv

Diane Miller Chief Scientific Communications Branch National Institute on Alcohol Abuse

and Alcoholism Bethesda, Maryland

Harry B. Montoya, M.A. President/Chief Executive Officer Hands Across Cultures Espanola, New Mexico

Richard K. Ries, M.D. Director/Professor Outpatient Mental Health Services Dual Disorder Programs Seattle, Washington

Gloria M. Rodriguez, D.S.W. Research Scientist Division of Addiction Services NJ Department of Health and Senior Services Trenton, New Jersey

Everett Rogers, Ph.D. Center for Communications Programs Johns Hopkins University Baltimore, Maryland

Jean R. Slutsky, P.A., M.S.P.H. Senior Health Policy Analyst Agency for Healthcare Research & Quality Rockville, Maryland

Nedra Klein Weinreich, M.S. President Weinreich Communications Canoga Park, California

Clarissa Wittenberg Director Office of Communications and

Public Liaison National Institute of Mental Health Kensington, Maryland

Consulting Members Paul Purnell, M.A. Social Solutions, L.L.C. Potomac, Maryland

Scott Ratzan, M.D., M.P.A., M.A. Academy for Educational Development Washington, DC

Thomas W. Valente, Ph.D. Director, Master of Public Health Program Department of Preventive

Medicine School of Medicine University of Southern California Alhambra, California

Patricia A. Wright, Ed.D. Independent Consultant Baltimore, Maryland

KAP Expert Panel and Federal Government Participants

xv

The Treatment Improvement Protocol (TIP) series supports SAMHSA’s mission of building resilience and facilitating recovery for people with or at risk for mental or substance use disorders by providing best-practices guidance to clinicians, program administrators, and payors to improve the quality and effectiveness of service delivery, and, thereby promote recov- ery. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and imple- mentation requirements. A panel of non-Federal clinical researchers, clin- icians, program administrators, and client advocates debates and discuss- es its particular areas of expertise until it reaches a consensus on best practices. This panel’s work is then reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have helped to bridge the gap between the promise of research and the needs of practicing clinicians and administrators to serve, in the most scientifically sound and effective ways, people who abuse substances. We are grateful to all who have joined with us to contribute to advances in the substance abuse treatment field.

Charles G. Curie, M.A., A.C.S.W. Administrator Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration

Foreword

xvii

Executive Summary

For men and women whose struggle with substance abuse brings them into contact with the legal system, the personal losses can be enormous: fami- lies can break apart, health deteriorates, freedom is restricted, and far too often, lives are lost. But this is just the beginning of the potential devasta- tion. Personal costs to the victims of crime are immeasurable. The effects of every theft, burglary, and violent crime reverberate throughout the whole community. Economic losses include the costs of arresting, process- ing, and incarcerating offenders, as well as the costs of police protection, increased insurance rates, and property losses.

Strong empirical evidence over the past few decades consistently has shown that substance abuse treatment reduces crime. For many people in need of alcohol and drug treatment, contact with the criminal justice sys- tem is their first opportunity for treatment. A substance use disorder may be recognized and diagnosed for the first time, and legal incentives to enter substance abuse treatment sometimes motivate the individual to begin recovery. For other offenders, arrest and incarceration are part of a recurring cycle of drug abuse and crime. Ingrained patterns of maladap- tive coping skills, criminal values and beliefs, and a lack of job skills may require a more intensive treatment approach, particularly among offend- ers with a prolonged history of substance abuse and crime.

This TIP was developed to provide recommendations and best practice guidelines to counselors and administrators based on the research litera- ture and the experience of seasoned treatment professionals. It covers the full range of criminal justice settings and all the phases through which an individual progresses in the criminal justice system. It addresses both clin- ical and programmatic areas of treatment. The consensus panel defined the areas highlighted below as important in efforts to achieve the treat- ment objectives of recovery and a life in the community for everyone.

xviii Executive Summary

Screening and Assessment A vital first step in providing substance abuse treatment to people under criminal justice supervision is to identify offenders in need of treatment. In the criminal justice system, screening often is equated with “eligibility,” and assessment often is equated with “suitabili- ty.” To do this effectively, the consensus panel recommends that protocols be developed to determine which offenders need substance abuse treatment, assess the extent of their treatment needs, and ensure that they receive the treatment they need. Obtaining accurate and reliable information during screening and assessment can be a challenge; offenders do not always accurately report drug or alcohol prob- lems. Other collateral sources of information (e.g., drug test results, correctional records) can be combined with self-report information to make referral decisions. For example, in many correctional facilities, urine tests are used to flag the need for treatment—even when an offender denies recent substance abuse.

Many offenders who abuse substances have co- occurring mental disorders that can make treatment more complex. They should there- fore be screened for other psychological or emotional problems. Offenders who are initial- ly assessed as having symptoms of co-occurring disorders should be evaluated over an extended period of time to determine whether these symptoms resolve in the absence of substance use.

A significant number of offenders who abuse substances also have histories of trauma and physical or sexual abuse. Screening and assess- ment of a history of physical and sexual abuse should be conducted routinely, particularly in settings that include female offenders. Staff training is needed to develop effective inter- viewing approaches related to the history of abuse, counseling approaches for addressing abuse and trauma issues, and in making refer- rals to mental health services.

Triage and Placement in Treatment Services Information obtained in screening and assess- ment is used to place offenders in the treatment program that is best suited to their needs. More offenders can receive appropriate treatment if a range of substance abuse treatment options is provided in criminal justice settings, particu- larly in institutions and community settings where offenders are supervised for long periods of time. In addition to key information regard- ing substance abuse problems, risk for criminal recidivism, and mental health problems, triage and placement decisions also should consider the offender’s motivation and readiness for change, the length of sentence or incarceration, history of previous treatment, violence poten- tial, and other related security or management issues. The consensus panel recommends that in general, offenders who have moderate-to- high levels of substance abuse problems and criminal risk should be prioritized for place- ment in substance abuse treatment services, rather than in other types of institutional pro- grams.

Treatment Planning After placement, a treatment plan is developed that specifies which services the offender-client needs, at what level of intensity, and which of the available resources (e.g., personal, pro- gram-based, or criminal justice) will be most beneficial. The treatment plan takes into con- sideration the severity of substance abuse- related problems and the presence of co-occur- ring mental disorders because these influence the treatment approach. Also important are factors such as criminal attitudes and psy- chopathy, which may suggest persistent crimi- nality unrelated to the need to maintain a drug habit. The degree to which an individual is motivated and ready for change is another crit- ical factor that will determine whether motiva- tional enhancement interventions, sanctions, or more self-directed treatments are appropriate. Finally, personal strengths are taken into

xixExecutive Summary

account in planning. The offender should be involved in the treatment planning process.

The most effective treatment programs have the resources necessary for comprehensive assessment and treatment planning activities including adequate staffing, clerical support, and access to computers and management information systems that contain information regarding the offender. Mechanisms for sharing information among agencies will expedite treat- ment as clients move through the criminal jus- tice system. For example, monitoring, consulta- tion, and written agreements are needed to define the types of information that will be shared, with whom, and under what circum- stances. Procedures that ensure the smooth and timely flow of relevant information will enable staff to proceed with treatment without interruption. Effective management informa- tion systems allow for access to clinical infor- mation as well as other offender data. At the same time, however, confidentiality regulations require that clinical information be maintained separately from the corrections or supervision case files, and access to clinical files be restrict- ed to staff who have primary clinical responsi- bilities.

Major Treatment Issues and Approaches Clients under criminal justice supervision share many of the same clinical issues faced by others receiving substance abuse treatment, but some are unique. For example, many offenders have problems with the very issues that brought them to the attention of law enforcement, particularly, criminal thinking and values. These clients often have problems dealing with anger and hostility and have the stigma of being criminals, along with the guilt and shame that accompany this stigma. Their identity as criminals may need to be offset by exposure to more prosocial values and identi- ties such as those of family member and wage earner.

Adapting Offender Treatment for Specific Populations General clinical strategies for working with offender-clients include interventions to address criminal thinking and to provide basic problemsolving skills; however, substance abuse treatment approaches should be modi- fied to meet specific client needs. Because of their histories or life experiences, certain popu- lations are recognized as having somewhat dif- ferent treatment needs. For example, people from cultural minorities have had different stresses from those in the majority culture. Women are more likely to have been trauma- tized by physical and sexual abuse than men and to have urgent concerns about their chil- dren. Offenders with co-occurring substance use and mental disorders need help that inte- grates treatment for both. Other groups with specific needs include older adults, violent offenders, people with disabilities, and sex offenders.

Treatment Issues Specific to Pretrial and Diversion Settings Treatment varies not only because of the specif- ic population to which an offender belongs but also because of a client’s stage in the criminal justice system. After arrest and before trial, a large number of individuals move relatively quickly through the system, and many different agencies are involved with each case and its supervision. If offered, the offender may opt for treatment instead of formal charges, trial, sentencing, incarceration, or to reduce the length of incarceration.

Variations in local prosecution and diversion practices may affect a jurisdiction’s ability to develop criminal justice and treatment link- ages. Not all jurisdictions have established pro- cedures or programs for individuals who abuse substances; those jurisdictions that do have programs to treat offenders often maintain

xx

such programs with limited resources. However, the pressure of overcrowded jails and prisons is serving to expand and institu- tionalize programs for drug treatment in pre- trial and diversion settings nationwide. Still, outside of formal drug court and diversion pro- grams, treatment access is limited. Types of treatment used in the pretrial setting are neces- sarily brief and include brief motivational interventions, behavior contracts, and refer- rals to detoxification and other services. A variety of sanctions also are available.

In the pretrial setting, the question of an indi- vidual’s guilt or innocence has not been legally determined. It is vitally important, therefore, to note that treatment should not compromise the due process rights of defendants. Treatment professionals need to bear in mind the presumption of innocence that exists during the pretrial period. Defendants’ due process rights affect what they are willing to agree to and the type of information that they are will- ing to disclose. Defendants should not be coerced into waiving due process rights, although a court may order substance abuse treatment as a condition of pretrial release.

Treatment Issues Specific to Jails Those incarcerated in jails are undergoing sig- nificant stress related to arrest, the uncertain- ties of their legal situation, and the potential loss of their job or custody of their children. Appropriate treatment services for these indi- viduals are based on the expected duration of incarceration and the information obtained from screening for a variety of possible prob- lems. Brief treatment (less than 30 days) usual- ly focuses on supplying information and mak- ing referrals but can include motivational inter- viewing. Short-term programs (1–3 months) have the time to work on communication, prob- lemsolving, and relapse prevention skills; intro- duce anger management techniques; and encourage participation in self-help groups.

Longer term programs (3 months–1 year) can provide additional skills training, vocational and educational activities, and examine crimi- nal thinking errors. The consensus panel rec- ommends that jail staff implement discharge planning that includes gathering information regarding the need for a range of community services, including housing and health care.

Treatment Issues Specific to Prisons The unique characteristics of prisons have important implications for developing and implementing treatment programs. In-prison drug abuse treatment, particularly when fol- lowed by community-based continuing care treatment, has been credited with reducing short-term recidivism and relapse rates among offenders who are involved with drugs. More recently, the sustained effects on longer term outcomes have been documented by studies indicating that 9–12 months of prison treat- ment followed by at least 3 months of communi- ty treatment are needed to produce significant improvement and reductions in recidivism and relapse. Because of the comparative stability of the prison population, several treatment options of differing intensities can be made available. The full range of services can be offered, including comprehensive assessment; treatment planning; placement; group, individ- ual, family, and specialty group counseling; self-help groups; educational and vocational training; and planning for transition to the community. Therapeutic communities (TCs) are among the most successful in-prison treat- ment programs. They are highly structured, hierarchical, and intense interventions lasting a minimum of 6 months. TC participants live together, often separate from the general prison population, and take responsibility for their recovery process. Participants work at increas- ingly more responsible positions as they learn self-sufficiency and become competent.

Executive Summary

xxi

Treatment for Offenders Under Community Supervision Parolees and probationers are both under com- munity supervision; nonetheless, they generally represent different ends of the criminal justice continuum. Whereas parolees are serving a term of conditional supervised release following a prison term, probationers are under commu- nity supervision instead of a jail or prison term. Both parolees and probationers generally can be controlled and managed effectively by a combination of treatment and surveillance while under community supervision at a far lower cost than incarceration in jail or prison. The level of supervision varies according to individual circumstances, including the terms under which probation or parole was granted. Offenders under community supervision in urban areas who have substance use disorders have available several levels treatment and supervision, including residential, outpatient, halfway, and day reporting centers. Parolees may have difficulty meeting their basic needs when they are released and benefit from case management services to help with housing and employment. Reunification with family mem- bers and social support may also prove prob- lematic.

Relapse prevention is extremely important for those under community supervision. Relapse, which is not unusual, can be met by increased supervision and an intensification of the level of treatment. Likewise, the intensity of supervi- sion and treatment should decrease as the indi- vidual meets treatment goals. For both parolees and probationers, reassessment should be peri- odically conducted throughout the phase of community supervision. Following their contact with the criminal justice system, both parolees and probationers benefit from continuing con- tact with the substance abuse treatment system as a means of reducing relapse and recidivism.

Key Issues Related to Program Development Offender-clients will best be served by sub- stance abuse treatment and criminal justice systems that are working together to help them in recovery and in becoming law-abiding citi- zens. This requires leaders in both systems who promote their mutual goals, endorsement for mutual goals from leaders, clarification of the goals, and recruitment of stakeholders in pur- suit of the goals. The challenge for substance abuse treatment practitioners and criminal jus- tice professionals is to work together to provide a coordinated response to ensure that offend- ers’ needs are addressed while protecting pub- lic safety.

Executive Summary

1 Introduction

In This Chapter…

The Purpose of This TIP

Key Definitions

Audience for This TIP

Contents of This TIP

When the prison gates slam behind an inmate, he does not lose his human quality; his mind does not become closed to ideas; his intellect does not cease to feed on a free and open interchange of opinions; his yearning for self-respect does not end; nor is his quest for self-realiza- tion concluded. If anything, the needs for identity and self-respect are more compelling in the dehumanizing prison environment.

—Thurgood Marshall (Procunier v. Martinez, 416 U.S. 396 [1974])

Overview Research consistently demonstrates a strong connection between crimi- nal activity and substance abuse (Chaiken 1986; Inciardi 1979; Johnson et al. 1985). Eighty-four percent of State prison inmates who expected to be released in 1999 were involved with alcohol or illicit drugs at the time of their offense; 45 percent reported that they were under the influence when they committed their crime; and 21 percent indicated that they committed their offense for money to buy drugs (Office of National Drug Control Policy [ONDCP] 2003). Data from the Arrestee Drug Abuse Monitoring program indicate that in 2000, 64 percent of male arrestees tested positive for at least one of five illicit drugs (cocaine, opioids, marijuana, methamphetamines, and PCP). Additionally, 57 percent reported binge drinking in the 30 days prior to arrest, and 36 percent reported heavy drinking (Taylor et al. 2001).

The consequences of crime related to substance abuse are substantial. The Bureau of Justice Statistics reports that in 1999 alone, 12,658 homicides—4.5 percent of all homicides for that year—were drug relat- ed (Dorsey et al. 1999). The emotional costs to people with substance use disorders, their families, and the victims of their crimes are immea- surable. The ONDCP estimates that the total crime-related costs of drug abuse were more than $100 billion in 2000 (ONDCP 2001).

The devastating emotional and financial costs of drug-related crimes have led to a number of strategies to break the link between drugs and

1

crime, including stricter drug laws, “three strikes and you’re out” legislation, increased surveillance, mandatory sentencing laws, and severe penalties for drunk drivers, to name just a few. These approaches have had mixed results, and opinions vary on their useful- ness.

One consistent research finding is that involvement in substance abuse treatment reduces recidivism (a tendency to return to criminal habits) for offenders who use drugs (Anglin and Hser 1990; Harwood et al. 1988; Hubbard et al. 1984, 1989; Knight et al. 1999a; Martin et al. 1999; McLellan et al. 1983; Wexler et al. 1988, 1999a; Wisdom 1999). For example, when researchers con- ducted followup studies of clients treated through comprehensive treatment demonstra- tion programs funded by the Center for Substance Abuse Treatment (CSAT), they found substantial reductions in criminal activity, including a 64-percent decrease in arrests (Wisdom 1999). In part because of the reduced criminal activity associated with sub- stance abuse treatment for offenders, treat- ment has also been found to be cost-effective. According to the California Drug and Alcohol Treatment Assessment study (Gerstein et al. 1994), for example, every dollar invested in treatment saved approximately $7 in future costs.

In response to research demonstrating the success of treatment in reducing criminal activity as well as the cost benefits of such treatment, policymakers over the past two decades have implemented a wide variety of strategies at the Federal, State, and local lev- els. These initiatives are aimed at improving the availability and quality of treatment for offenders. Drug Courts—courts with special unified dockets for individuals charged with crimes who are drug or alcohol involved— serve to divert offenders with substance use disorders away from the criminal justice sys- tem into a supervised treatment plan or to incorporate a coerced treatment plan as part of a judicial sentence. Other programs have been established for people with special

needs, including individuals with co-occurring mental disorders. At the same time, other ini- tiatives have increased funding for people already in prisons and jails. Examples of such initiatives include

• Project REFORM and later Project RECOVERY. These programs, funded in the late 1980s by the Bureau of Justice Assistance (BJA) and in the early 1990s by CSAT, provided technical assistance to 20 States in planning and developing substance abuse programming for prisoners with sub- stance abuse problems (Wexler 1995).

• Residential Substance Abuse Treatment for State Prisoners Formula Grant Program. This program funds States seeking to devel- op comprehensive approaches to treatment for offenders who abuse substances, includ- ing intensive programs for inmates and relapse prevention training. Further infor- mation is available at www.cfda.gov.

• The National Drug Control Strategy, pre- pared annually by the Office of National Drug Control Policy (1997, 1998, 1999, 2000, 2001). This program has encouraged the development of treatment and rehabili- tation services for offenders who use drugs (e.g., Treatment Accountability for Safer Communities, formerly Treatment Alternatives to Street Crime; drug court programs; prison treatment programs). For further information, go to www.whitehouse- drugpolicy.gov/.

• The BJA, Office of Justice Programs, U.S. Department of Justice. Formerly known as the Drug Courts Program Office, estab- lished to administer the drug court grant program, the BJA provides financial and technical assistance, training, and program- matic guidance for drug courts throughout the country. BJA offers grants that enable communities to develop, implement, or improve drug courts. Information is avail- able at www.ojp.usdoj.gov/BJA/.

• The Serious and Violent Offender Reentry Initiative. In conjunction with several Federal partners, the U.S. Department of Justice is spearheading this initiative to

2 Chapter 1

provide funding to promote successful rein- tegration of serious, high-risk offenders into the community. The Initiative seeks to address all obstacles to successful reentry, including substance abuse. Information is available online at www.ojp.usdoj.gov/ reentry/learn.html.

In part because of initiatives such as these, the availability of substance abuse treatment for criminal offenders is on the rise. After 3 years of decline in the mid-1990s, the number of inmates in drug treatment programs began rising again in 1997 and 1998 (Corrections Yearbook 1998). A report based on a 1997 nationwide survey of Federal and State cor- rectional facilities (Office of Applied Studies 2000) indicates that 93.8 percent of Federal prisons and 56.3 percent of State prisons pro- vide some form of substance abuse treatment.

Although an increasing number of prisons offer some form of treatment, the actual num- ber of programs and slots remains limited (National Center on Addiction and Substance Abuse at Columbia University 1998; Peters and Matthews 2002). For example, although more than half of prison inmates have a life- time prevalence of drug use disorders (Peters et al. 1998), fewer than 15 percent of inmates receive substance abuse treatment services while in prison (Mumola 1999; Simpson et al. 1999b). Moreover, while the number of sub- stance abuse programs for offenders is on the rise, so too is the number of offenders in need of services. Substance abuse treatment ser- vices for offenders have not kept pace with the growing need for these services (Belenko and Peugh 1998; Simpson et al. 1999b).

This TIP highlights some of the best practices and innovative programs created to treat offenders. It describes the unique needs of offenders with substance abuse and depen- dence disorders. Finally, it addresses the challenges counselors and criminal justice personnel are likely to face at every stage of the criminal justice continuum.

The Purpose of This TIP This TIP updates and combines three TIPs originally published in 1994 and 1995: TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994d); TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (CSAT 1994a); and TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System (CSAT 1995b).

The new TIP pre- sents clinical guide- lines to assist coun- selors in dealing with problems that rou- tinely arise because of their clients’ sta- tus in the criminal justice system. These clients have multiple needs; they often have poor health, have histories of trauma, lack job and communication skills, and have edu- cational deficits. A special feature throughout the TIP—“Advice to the Counselor”—pro- vides the TIP’s most direct and accessible guidance for the counselor. Readers with basic backgrounds, such as addiction coun- selors or other practitioners, can study these boxes first for the most immediate practical guidance. In particular, the Advice to the Counselor boxes provide a distillation of what the counselor needs to know and what steps to take, which can be followed by a more detailed reading of the relevant material in the section or chapter.

The events of September 11, 2001, dramati- cally altered the political climate of our Nation and caused a shift in focus from the “tough on drugs” policies previously in place

3Introduction

One consistent

research finding is

that involvement

in substance abuse

treatment reduces

recidivism for

offenders who use

drugs.

to the war on terrorism. These changes have impacted both the sanctions against people in the criminal justice system and the availabili- ty of substance abuse treatment for those populations. While it is beyond the scope of this TIP to address the implications of these shifts or to predict their ultimate outcomes, the core content of this document reflects the current best practices for providing substance abuse treatment for adults in the criminal justice system.

This TIP aims to provide tools and resources to increase the availability and improve the quality of substance abuse treatment to crimi- nal justice clients. It should assist the crimi- nal justice system in meeting the challenges of working with offenders with substance use disorders and encourage the implementation of evidence-based clinical approaches to treatment.

Other guiding principles of this publication are to

• Provide the relevant information that will inform and enable treatment providers to feel more confident in their approach to offender and ex-offender populations.

• Help people in community treatment under- stand the criminal justice system and how it works in step with their treatment services.

• Encourage collaboration between the crimi- nal justice and treatment communities.

• Help readers understand the multiple per- spectives that often lead to confusion and misunderstandings—public safety versus public health, treatment versus corrections, differing client needs, issues of culture and society, and local characteristics of the criminal justice system.

• Provide practical solutions and approaches to complex problems.

Key Definitions In this TIP, the term “substance abuse” is used to denote both substance abuse and sub-

stance dependence as they are defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000). This term was chosen part- ly because substance abuse treatment profes- sionals commonly use the term “substance abuse” to describe any excessive use of addic- tive substances. Readers should attend to the context in which the term occurs to determine the possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders described by DSM-IV-TR.

According to DSM-IV-TR, substance abuse is a maladaptive pattern of substance use marked by recurrent and significant negative consequences related to the repeated use of substances. Substance dependence is defined as a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual is continuing use of the substance despite significant substance-related prob- lems. A person experiencing substance depen- dence shows “a pattern of repeated self- administration that usually results in toler- ance, withdrawal, and compulsive drug-tak- ing behavior” (p. 192). A diagnosis of sub- stance dependence can be applied to every class of substances except caffeine.

Treatment is defined according to the Institute of Medicine (IOM 1990), as cited in CSAT’s National Treatment Plan Initiative (CSAT 2000a, b):

Treatment refers to the broad range of [pri- mary and supportive] services—including identification, brief intervention, assessment, diagnosis, counseling, medical services, psy- chiatric services, psychological services, social services, and followup—provided for people with alcohol [and/or drug] problems. The overall goal of treatment is to reduce or eliminate the use of alcohol [and/or drugs] as a contributing factor to physical, psychologi- cal, and social dysfunction and to arrest,

4 Chapter 1

retard, or reverse the progress of any associ- ated problems (CSAT 2000a, p. 7).

The criminal justice system, as discussed in this TIP, includes four subsystems: pretrial and diversion settings, jails and detention centers, prisons (State and Federal), and community supervision settings. Definitions of other terms relevant to criminal justice and substance abuse treatment are given in appendix B, Glossary.

For the purposes of this TIP, an offender is a person who has been arrested, charged with a crime, or convicted of a crime and under the supervision of the criminal justice system.

Audience for This TIP This TIP is written primarily for substance abuse counselors and clinicians who treat clients involved in the criminal justice system or who are under full or partial supervision and for administrators whose programs serve clients under criminal justice supervision. It also will be useful for counselors who work in correctional institutions and those in communi- ty agencies with clients on probation, parole, or pretrial release.

Others who work in the criminal justice sys- tem may also find this TIP helpful. This includes judges and prosecutors; probation and parole officers, case managers, public defenders and other criminal defense attor- neys; jail, detention center, and prison per- sonnel; and people working in pretrial/diver- sion and in probation and parole settings.

Program developers and grant writers will find that this TIP provides information about a variety of programs and resources. Finally, this TIP is of value to anyone concerned with reducing overcrowding in correctional facili- ties, addressing the crimes committed by untreated drug-involved offenders, and meet- ing the challenges that these offenders face on their journey toward recovery.

Contents of This TIP The chapters that follow will focus on the fol- lowing areas:

• Chapter 2 focuses on screening and assess- ment of criminal justice clients in the rele- vant domains. It includes a discussion of special concerns (e.g., gender and sexual orientation, literacy, a client’s primary lan- guage, and learning disabilities) and specific populations. See also appendix C, which contains more information on screening and assessment instru- ments.

• Although it is rec- ognized that treat- ment can be effec- tive, it is also clear that different treatment approaches may work better with some clients than with others. Chapter 3 discuss- es triage and place- ment in treatment services and reviews the com- plex area of treat- ment matching.

• Chapter 4 discusses the available treat- ment options in the criminal justice system. It also presents guidelines for devel- oping treatment plans.

• Chapter 5 addresses the major treatment issues for offenders who use substances. These include a wide range of themes, including engagement and retention, stigma and shame, the client–counselor relation- ship, and major treatment levels (e.g., resi- dential, nonresidential, outpatient, commu- nity supervised, and self-help and other ancillary services).

5Introduction

This TIP aims to

provide tools and

resources to

increase the

availability and

improve the

quality of

substance abuse

treatment to crim-

inal justice clients.

• Chapter 6 describes treatment issues and approaches for special populations for whom modifications in treatment may be appropriate: people of ethnic and racial minorities, women, violent offenders, peo- ple with disabilities, older inmates, people with co-occurring substance use and mental disorders, and sex offenders, among others.

• Chapters 7 through 10 describe the specific treatment needs and strategies for individu- als in particular criminal justice settings.

Chapter 7 addresses treatment provided in diversion and other pretrial settings. Chapter 8 provides a detailed discussion of treatment for offenders in jails and deten- tion centers, while chapter 9 focuses on offenders in prison. Chapter 10 outlines treatment for people under community supervision.

• Finally, chapter 11 discusses the issues related to program development.

6 Chapter 1

7

2 Screening and Assessment

In This Chapter… Definitions of Terms

Screening Guidelines

Assessment Guidelines

Key Issues Related to Screening and Assessment

Areas To Address in Screening and Assessment

Selection and Implementation of

Instruments

Screening and Assessment Considerations for

Specific Populations

Integrated Screening and Assessment—Sample

Approaches

Conclusions and Recommendations

Overview Screening and in-depth assessment are important first steps in the sub- stance abuse treatment process; currently no comprehensive national guidelines for screening and assessment approaches exist in the criminal justice system. In the absence of such guidelines, information in this chap- ter can help clinicians and counselors develop effective screening and referral protocols that will enable them to

• Screen out offenders who do not need substance abuse treatment.

•Assess the extent of offenders’ treatment needs in order to make appro- priate referrals.

•Ensure that offenders receive the treatment that they need, rather than being released into the community with a high probability of re-offend- ing.

This chapter addresses the issues relevant to screening and assessment and makes recommendations for the appropriate use of screening and assess- ment tools in specific settings. For information on how to use screening and assessment to match the offender to services and to identify an appro- priate treatment plan, see chapters 3 and 4. For more information on spe- cific screening and assessment instruments see appendix C.

Definitions of Terms Information gathered during screening and assessment plays an impor- tant role in identifying offender needs and making appropriate referrals for services. Throughout this TIP, the following definitions are used for screening, assessment, and related terms in the criminal justice setting:

• Screening—A process for evaluating someone for the possible pres- ence of a particular problem. The screening process does not neces- sarily identify what kind of problem the person might have or how serious it might be but determines whether or not further assessment is warranted. Screening does not typically include assignment of DSM-

IV-TR (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [American Psychiatric Association {APA} 2000]) diagnoses of alcohol or drug abuse or dependence and may only identify DSM-related problem areas. During the screening process staff members use instru- ments that are limited in focus, simple in format, quick to administer, and usually able to be administered by nonprofessional staff. There are seldom any legal or profes- sional restraints on who can be trained to conduct a screening.

• Assessment—A process for defining the nature of a problem and developing specific treatment recommendations for addressing the problem. A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor to understand the client’s readi- ness for change, problem areas, any diagno- sis(es), disabilities, and strengths. The assessment process typically requires trained professionals to administer and interpret results, based on their experience and training. A clinical diagnosis has important legal ramifications since judges tend to rely on assessments to identify an offender’s needs and risks, and to deter- mine the offender’s disposition.

In correctional settings, “screening” and “assessment” are equated with “eligibility” and “suitability,” respectively. “Eligibility” is

determined in pretrial and jail settings by screening for offenders who may need sub- stance abuse treatment. “Suitability” for placement in one of several different levels of treatment services is determined by an assess- ment to help identify key psychosocial prob- lems related to referral to treatment and/or supervision. Accordingly, the following con- siderations are suggested:

•Eligibility—Does the offender meet the sys- tem’s criteria for receiving treatment ser- vices? A quick screen, typically applicable in prisons and community corrections set- tings, can determine whether a person war- rants assessment to determine if that person has a drug or alcohol problem.

•Suitability—Is the offender suitable for the type of program services that are available? An assessment can determine whether the offender is capable of benefiting from treat- ment or responding to a particular inter- vention. The question of suitability arises once it has been determined that offenders meet the eligibility criteria for receiving ser- vices.

In essence, screening and assessment vary based on the goals of the evaluation and the setting where they are used. For drug court and jail settings, a source for operational treatment and criminal justice definitions is the article “Guideline for Drug Courts on

8 Chapter 2

Common Myths About Screening and Assessment

Following are several common myths about substance abuse screening and assessment, and the facts that debunk those myths.

• Myth: Screening and assessment are no better than intuition in detecting a person’s need for treat- ment.

• Fact: Objective screening and assessment measures can result in treatment that is better targeted to a client’s needs, resulting in better outcomes.

• Myth: Only a single screening is needed to place people in different levels of treatment services. • Fact: Accurate evaluation requires a battery of assessment instruments that examine how substance

use has affected all the domains of the client’s life. When treatment options are severely limited, how- ever, a basic screening may be sufficient to determine both eligibility and suitability for treatment.

Screening and Assessment” (Peters and Peyton 1998).

Screening Guidelines This section presents broad guidelines and con- siderations for developing an effective screen- ing protocol. (See section below for additional guidelines related to assessment protocols.)

More specific guidelines based on the criminal justice setting and the characteristics of the population are discussed in later sections.

When creating a screening protocol, coun- selors will need to ask the following questions:

• What is the purpose of the screening?

• What screening tools will be used and under what circumstances?

9Screening and Assessment

• Myth: Untrained professionals can conduct screening and assessments. • Fact: Although some screenings can be administered and scored without significant training, place-

ment decisions are greatly improved when they are made by professionally trained staff. This includes staff with relevant certification in substance abuse treatment, those with advanced professional degrees, and those with specialized training in the use of particular screening and assessment instru- ments. For those screening and assessment approaches that require an interview with the offender, specialized training is also needed in basic counseling techniques such as rapport building and reflec- tive listening. Use of trained professional staff in the triage and placement process helps to minimize the number of inappropriate referrals for treatment.

• Myth: Screening and assessment are always compromised because you cannot trust self-report infor- mation from offenders.

• Fact: Research generally validates the reliability, and to some degree, the validity of information obtained through self-reports. Collateral sources such as the offender’s family and friends can improve the reliability of the information gathered (or “the full picture”). Offenders do supply a cer- tain amount of misinformation in some settings to avoid unwanted consequences, however.

• Myth: All screening and assessment instruments are equally effective. • Fact: Research shows significant variability in the reliability and validity of different instruments with

different populations.

• Myth: Because an instrument is widely used, it must be effective. • Fact: Many highly marketed and widely used instruments do not have a research base supporting the

validity of their use. In fact, some of the widely marketed and used instruments have been shown to be less effective than those available in the public domain.

• Myth: Screening and assessment should not examine the history of physical and sexual abuse and related trauma because this may aggravate the offender’s level of stress and psychological instability, and staff may not be able to deal effectively with the consequences.

• Fact: Screening and assessment of all forms of abuse is essential for both male and female offenders, because it is now recognized that the effects of trauma contribute to many mental disorders. Clinical outcomes are likely to be compromised if these abuse and trauma issues are not explored, and if strategies addressing these issues are not developed and integrated into treatment plans for mental and substance use disorders. However, it is important to emphasize that in screening for a history of trau- ma it can be damaging to ask the client to describe traumatic events in detail. To screen, it is impor- tant to limit questioning to very brief and general questions, such as “Have you ever experienced childhood physical abuse? Sexual abuse? A serious accident? Violence or the threat of it? Have there been experiences in your life that were so traumatic they left you unable to cope with day-to-day life?”

Purpose of Screening The first issue to consider is the purpose of the screening. In addition to screening for drug use, counselors may consider screening for other problem areas. For example, given that many infectious diseases are associated with the use of drugs (Varghese and Fields 1999), health screening can be important in identifying offenders in need of healthcare services to ensure that clients receive needed medication and to prevent the spread of dis- ease. Screening to identify special needs for offenders with co-occurring mental problems can improve the effectiveness of treatment. It can identify individuals who may pose a threat to themselves or others, prevent crises, and promote immediate intervention. Screening content should identify key issues that need to be addressed in placing offenders in treatment. Content can be specific to sever- al domains, including substance use, crimi- nal, physical health, mental health, and spe- cial considerations. Figure 2-1 summarizes the information relevant to each domain.

Screening guidelines will vary by setting. A professional screening of an individual who has just been arrested will include different questions and require different information than a long-term prisoner being considered for parole. For a probationer, screening might be used to determine the appropriate level of supervision; a jail inmate may be screened to assess his or her suitability for treatment. Figure 2-2 (see p. 12) highlights the different screening considerations for each setting.

Selection of Screening Tools In addition to identifying the purpose of screening, the protocol should also identify the screening tools to be used and the condi- tions under which they are used. Basic infor- mation can be acquired from any number of sources, including

• Booking records

•Self-report/interview information

•Results of instruments and surveys adminis- tered

•Past correctional records (presentence investigations)

•Past treatment records

•Police reports

•Correctional staff reports (for bail hearings, early release)

•Prior offense records (for driving under the influence [DUI], possession, trafficking)

•Emergency medical reports

•Drug test results (from examination of hair, sweat, urinalysis, Breathalyzer®)

Some jurisdictions may be required to use a particular instrument or information source to gather information consistently from all offend- ers, even though corroborative information, such as urine test results, is often available. Such universal screenings can help route non- violent, low-risk offenders to treatment place- ments in the community so that recovery can begin. A more detailed discussion of selection of screening instruments is provided later in this chapter.

Assessment Guidelines The goal of assessment is to gather enough information about clients to describe how the treatment system can address their substance abuse problems and the impact of those prob- lems. An assessment examines how the offend- er’s emotional and physical health, social roles, and employment could be affected by substance abuse (Center for Substance Abuse Treatment [CSAT] 1994a). In addition, assessments can help identify the factors that could prompt a return to drug use or criminal behavior. These include lack of social support networks, unstable employment history, poor health, criminality, unresolved legal prob- lems, inadequate housing, lack of motivation to change, a history of physical and sexual abuse, mental illness, learning disabilities, and other social and psychological factors. These factors need to be carefully examined during assessment to plan for potential gaps

10 Chapter 2

11Screening and Assessment

Figure 2-1 Screening Guidelines by Domain

Domain Information

Substance Use • Substance use history • Motivation and desire for treatment • Severity and frequency of use • Detoxification needs, acute intoxication • Treatment history (e.g., number and type of episodes, outcomes)

Criminal Involvement

• Criminal thinking • Current offense(s) • Prior charges • Prior convictions • Age at first offense • Type of offense(s) • Number of incarcerations • Prior successful completion of probation or parole drug use offenses • Prior involvement in diversionary programs • History of diagnosis of any personality disorder

Health • Intoxication, infectious disease (tuberculosis, hepatitis, sexually transmitted diseases, HIV status)

• Pregnancy • General health • Acute conditions

Mental Health • Suicidality • History of treatment and prior diagnosis • Past diagnoses • Treatment outcome • Current and past medications • Acute symptoms • Psychopathy

Special Considerations

• Educational level • Reading level/literacy • Language/cultural barriers • Physical disability • Developmental disability • Learning disability • Health and biomedical record • Housing • Dependents/family issues • History of abuse (victim and/or perpetrator), including trauma experienced as a result of

physical and sexual abuse

in services that can affect relapse and crimi- nal recidivism.

While assessments are more comprehensive than screenings, their depth and scope varies across settings according to the following fac- tors:

• Amount of time available to conduct the assessment

• Physical setting of assessment (e.g., holding pen, booking room, medical unit, reception center, lockup, community/corrections office)

• Factors influencing the confidentiality or pri- vacy of the assessment process and the uses of assessment findings

•Availability of qualified staff, caseload vol- ume, and interagency cooperation

•Availability of financial resources (e.g., staffing, type of assessment chosen)

•Availability of treatment options in the community

•Number of sources of information

The instruments and sources of information used during an assessment are determined by the purpose of the assessment. Jurisdictions may elect the quickest and most efficient approach to assess who goes into treatment. In other cases, the court may want the great- est amount of information available about an

12

Figure 2-2 Screening Guidelines by Setting

Setting Purpose Special Considerations

Jails • For early identification, if getting out of jail early

• To determine eligibility for drug courts and pretrial diversion programs

• For diversion to specialized mental health courts or programs focused on behavioral problems

• To determine behavioral management prob- lems and acute needs (including crisis inter- vention)

• To identify suitability for placement in jail treatment programs

• For classification to different housing units

Look for previous correctional substance abuse treatment, readiness for treatment, past institutional behavior problems, prior correctional treatment, and court orders.

Prisons • To match time left to serve with time for receiving treatment or for custody level classi- fication

• To identify suitability for placement in prison treatment programs

Look at prison record, treatment history (including treatment for issues other than substance abuse), and behavior.

Pretrial and Community Supervision

• To determine the need for housing, transporta- tion, employment, or economic benefits

• To identify suitability for placement in commu- nity treatment programs

• To assess for public safety risk and level of supervision needed, pursuant to consideration for placement in diversion programs

Look for community or corrections records or collateral information (e.g., information from family members).

Chapter 2

offender. In this case, in addition to police, corrections, and medical records, an assess- ment should include family and other collat- eral sources for historical information.

The following guidelines pertain to assessment protocols:

• Purpose—In pretrial or diversion settings, assess for linkage to the community and placement to different types of services.

• Content—In all settings, deepen the infor- mation obtained from previous screenings (psychopathy, antisocial).

• Source—In pretrial or diversion settings, seek more expansive collateral information from family and social service staff. In jails, prisons, or community supervision settings, correctional officers and/or collateral offenders may be additional sources of information.

Once a screening has identified the need for treatment, assessments should be conducted before offenders are given permanent place- ments. Assessments feed into treatment plan- ning, decisions about treatment intensity and services needed (e.g., treatment planning and matching), and re-entry and continuing care plans.

Key Issues Related to Screening and Assessment The distinctions between screening and assess- ment are defined above. This section highlights key issues relevant to both.

Accuracy of Information Accuracy of screening and assessment infor- mation is clearly dependent on the honesty of the offender. It is critical to administer screening and assessment instruments in a way that encourages honest answers. The consequences of honest and dishonest responses should be clarified, and the setting for the screening can be important in this regard (Knight et al. 2002). Some factors that contribute to greater accuracy of responses include using collateral information, using concurrent drug testing, and reviewing with the offender the purposes of information obtained during screening and assessment.

In some contexts (e.g., pretrial and presen- tence settings), offenders are often concerned that screening and assessment results will be used against them; for example to coerce them into a long-term treatment program. The individual may also want to avoid being labeled as having an addiction problem. Conversely, an offender may purposely try to

skew the results to influence the outcome of trial, sentencing, or placement in custody and/or treatment settings. It is impor- tant for those administering screening and assessment to rec- ognize the factors that may influ- ence the accurate disclosure of information, and to craft their findings accordingly.

Unless potential concerns related to the screening and assessment process are addressed directly, it is unlikely that screening and assessment results will provide an

13

Advice to the Counselor: Screening and Assessment

• It is critical to administer screening and assessment instruments in a way that encourages honesty. Offenders often think the results of these screenings will be used against them and may try to skew the results to influ- ence the outcome of a trial.

• The consequences of honest or dishonest responses should be clarified with the offender.

• Counselors should use available collateral information, such as drug testing results, to verify the accuracy of the information.

Screening and Assessment

accurate picture of the offender’s substance abuse problems and treatment needs. Offenders should be briefed in advance regarding who will have access to screening and assessment information and how the information will be used. Counselors and criminal justice professionals should also clearly indicate their own role in the informa- tion gathering process. It may also help to address myths regarding court-ordered or other mandated treatment and treatment pro- gram requirements, and to describe the bene- fits of participating in treatment. Counselors working in criminal justice settings should also be aware of issues related to confidential- ity and informed consent in the context of screening and assessment (see CSAT 2004 and www.hipaa.samhsa.gov).

Continuity of Information Screening and assessment are not single events but continuous processes that can be repeated by a variety of professionals in a variety of settings (CSAT 1994a). Efforts should be made to ensure the continuity of the information and to preserve the rights of the client. Ongoing communication and data sharing are important aspects of the screening and assessment process. Substance abuse treatment and criminal justice system staff, at all points in the process, need to pass on information obtained from substance abuse screening and assessment. Key information can be summarized and consolidated using a brief format, but this information should be maintained in a case file—even if a client does not go on to criminal prosecution—so that it can be used in case of subsequent arrest. It is helpful to standardize the format used to doc- ument screening and assessment information so that staff can be trained to more readily access, interpret, and communicate this infor- mation (CSAT 1994a).

Effective treatment programs require assess- ment and coordination between substance abuse treatment and criminal justice pro- grams and an understanding of the goals of

both systems. Coordination also leverages the scarce resources for substance abuse treat- ment (CSAT 1994a). To encourage a team approach to treatment, assessment, referral, and case management, the consensus panel recommends that the two systems develop or strengthen arrangements that support link- ages at the institutional and procedural lev- els. In addition, cross-training can promote the use of screening and assessment results and can reduce duplication of efforts (CSAT 1994a).

Systemwide Information Sharing Frequently, those in the criminal justice sys- tem who conduct initial substance abuse screening and assessment maintain the infor- mation, while others who have contact with the offender later in the course of criminal justice processing have to rescreen or reassess the individual. (See CSAT 2004 and www.hipaa.samhsa.gov for information about confidentiality and certain restrictions regarding sharing of information.) The use of multilevel agreements to share information is one approach that can minimize duplication of screening and assessment activities. One way to achieve this is to convene stakeholder meetings with representatives from all of the involved agencies in the system to develop these agreements. The benefits of multilevel agreements tend to be quite persuasive. Following are two examples:

• Agency A is spending $15 per drug screen in addition to staff time. If that agency works out an implementation plan with Agency B, both agencies can share the information, avoiding the unnecessary costs of duplicat- ing tests.

• Hospitals that have laboratory test results can add them to a database to confirm or refute self-report information.

At each stage of the criminal justice process there can be individuals or agencies that do not support sharing of substance abuse

14 Chapter 2

screening and assessment information. These groups have legitimate concerns that need to be expressed, and they need to be brought into the decisionmaking process as full stake- holders. Jurisdictions that establish intera- gency agreements can preserve limited staff time and resources and help avoid unexpect-

ed resistance to systemwide sharing of screen- ing and assessment information at any stage in the criminal justice process. See the text box below for examples of programs that have developed multilevel agreements for sharing information systemwide.

15Screening and Assessment

Examples of Multilevel Agreements for Systemwide Sharing of Information

Developing multilevel agreements is a difficult task and can take years to complete. Large criminal jus- tice systems will clearly benefit from having an intermediary case management or placement system to increase communication and coordination between in-custody programs, community-based providers, and parole offices. Below are several working models of multilevel agreements for systemwide sharing of information.

Lane County, Oregon Lane County uses client consent and a multilevel agreement between agencies to facilitate sharing of information. In this model, the client and agencies must agree up front if someone wants shared access to information. A correctional/mental health official developed a screening and reporting system where every person in jail is screened for drugs, risk, and mental health with a brief instrument. The screening information is available systemwide (i.e., jail, diversion, and community programs), including a tear-off copy for mental health information (National GAINS Center 2000).

High Intensity Drug Trafficking Areas Automated Tracking System The University of Maryland developed a nonproprietary Management Information System (MIS) called HATS, the HIDTA [High Intensity Drug Trafficking Areas] Automated Tracking System, that links sub- stance abuse treatment, mental health, juvenile, and community information. HIDTA is a program with- in the Office of National Drug Control Policy that coordinates drug control efforts in 28 regions around the country. A layered set of informed consent agreements is used to provide different access levels to different stakeholders (e.g., judges, parole, treatment programs). Users gain HATS access by signing an agreement to share any improvements made to the system, to benefit all stakeholders. The MIS is in use from coast to coast as a seamless care screening, assessment, case matching, and monitoring database (Taxman and Sherman 1998). For more information, go to the Washington/Baltimore HIDTA HATS site at www.hidta.org.

Maricopa County, Arizona Maricopa County has a data-link feed between the jail and behavioral health authority to determine whether offenders entering jail have a previous record of mental health services or substance abuse treatment (National GAINS Center 1999c). (See also chapter 8.)

The Need To Rescreen and Reassess There are many reasons to rescreen and reassess. Offenders who may fear the conse- quences of self-disclosing substance abuse problems in one setting (e.g., pretrial deten- tion) may be more open to discussing their need for treatment at a later stage (e.g., com- munity supervision or prison).

Offenders’ motivation for treatment may change over time; for example, as they become more familiar with peer mentors, counseling staff, program expectations, and their own self-defeating behaviors from the past. Another example is participants in drug courts who initially appear resistant to treat- ment during status hearings and who are unresponsive to early efforts by the judge and/or treat- ment counselors to instill motiva- tion (e.g., through praise, use of sanctions, and engagement in more intensive treatment), but who later surprise program staff by their progress toward recov- ery over the course of a year or more of program participation. For these individuals, assessment

may reflect a gradual process of uncovering reasons to quit their substance use, and iden- tifying strengths that can be built on during treatment. Another key reason for conducting multiple screenings and assessments over time is that previous information obtained may become outdated and may not include recent events that are relevant to treatment, such as relapse episodes, undetected mental disor- ders, or domestic violence.

16

Examples of Multilevel Agreements for Systemwide Sharing of Information (continued)

Orange County Probation Department

As part of the implementation of Proposition 36, the Orange County (California) Probation Department developed an MIS that links the Drug and Alcohol Division of the County Health Care Agency (HCA) with myriad treatment providers in the county. The law requires that the offender have an assessment and be referred to treatment within 7 days of sentencing. In processing offenders, the Probation Department conducts an initial assessment, while the HCA conducts a clinical assessment to determine the appropriate treatment level. On receiving the case from the court, the Probation Department sends a referral through the system to HCA, who then completes the assessment, selects a provider, and sends a notice through the system to the selected provider. The system then allows the provider to send period- ic progress reports to the Probation Department, including when release of information forms have been signed, assessment levels, drug test results, and progress in treatment (Orange County Probation Department 2002).

Advice to the Counselor: The Need To Rescreen

• An offender’s motivation and willingness to enter treat- ment may change over time. Those who fear the conse- quences of self-disclosing substance abuse in a pretrial setting may be more open to discussing their need for treatment while under community supervision or in prison. Others who initially appear resistant to treatment may later surprise program staff by their progress toward recovery.

• Multiple assessments may uncover an offender’s reason to quit substance use and identify strengths that can be built on during treatment.

Chapter 2

Timing of Screening and Assessment In some criminal justice settings only a single screening is needed, due to limited treatment options available or to the fact that assess- ment will be provided at a later stage. This screening is typically focused on issues related to eligibility criteria and suitability for treat- ment. In cases in which several treatment options and sufficient time are available, screening is often followed by a more compre- hensive assessment.

Although screening is usually conducted as early as possible after the offender’s entrance into the criminal justice system, assessment may be delayed due to the offender’s sentence length, anticipated date of enrollment in sub- stance abuse treatment services, and other factors. For example, most prison treatment programs provide services for inmates who are serving the last 24 months of their sen- tence, and routinely wait to provide a com- prehensive assessment until the inmate is nearing the enrollment date for treatment ser- vices.

When Is a Formal Diagnosis Necessary? When identified with a diagnosis that will fol- low them throughout the system or even their lifetime (if entered into the criminal justice system’s computer), people sometimes feel labeled and stigmatized. This is particularly true of diagnoses related to mental disorders. Because symptoms of mental disorders are often mimicked by recent drug or alcohol use, or withdrawal from these substances, it is particularly important to defer diagnosis until an adequate assessment period is provided under conditions of abstinence. A “people first” description such as “offender who uses drugs” is preferable to the label “drug user.” Moreover, diagnostic classification can some- times preclude offenders from receiving need- ed services. For example, a mental disorder diagnosis can preclude access to substance

abuse services. Likewise, a substance abuse diagnosis can preclude access to mental health services, resulting in no services being rendered. A substance abuse diagnosis can also limit an offender’s access to certain work assignments or vocational training.

To avoid these problems, formal diagnoses should be made based on sound clinical prac- tice. A formal diagnosis may be required when

• Reimbursement for services requires it (e.g., Medicaid or Medicare reimbursement is not possible without a DSM-IV-TR code).

• Pharmacological intervention is suggested (e.g., methadone, Antabuse).

• Potential psychiatric concerns emerge (e.g., when the counselor is trying to rule out sub- stance abuse or when symptoms may be drug-induced, organic, or psychiatric).

• The counselor needs to clarify co-occurring disorders that affect treatment decisions.

• The information is for research or evaluation purposes.

Drug Testing Drug testing is frequently used as a screening device in community-based and institutional settings. For example, in pretrial settings drug testing is used to identify and monitor drug use and to reduce the number of re- arrests among defendants (Bureau of Justice Assistance 1999). A major objective of pre- trial drug testing is to offer courts alterna- tives to either detention or unsupervised release during the pretrial period. In commu- nity settings drug testing provides a powerful tool for treatment staff, the courts, and com- munity supervision staff to monitor and address relapse episodes and treatment progress. In institutional settings, drug testing is helpful in monitoring abstinence and can serve as an “early warning” device in detect- ing problems among therapeutic residential programs. In all settings, drug testing serves both as a deterrent to use and as a strong incentive for offenders to remain abstinent.

17Screening and Assessment

Because of advancements in drug testing tech- nologies, drug testing can easily be incorpo- rated into the pretrial risk assessment pro- cess. For instance, using hand-held devices, commercial laboratories can conduct analyses of urine, perspiration, and hair to identify the presence of a variety of drugs. Pretrial screening for five drugs can cost anywhere from $5 to $120 (Henry and Clark 1999). However, protocols for collecting, testing, and disposing of specimens must be carefully observed to preserve the chain of evidence in the pretrial setting. Counselors should ensure that the rights of detainees and offenders are not violated (see chapter 7).

Areas To Address in Screening and Assessment This section describes the key areas that the consensus panel felt were important for effec- tive screening and assessment.

Substance Abuse History Key areas addressed during substance abuse screening and assessment are reviewed in sev- eral published TIPs, including numbers 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994d); 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT 1994e); 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999c); and 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c). Major topics covered during screening and assessment include observable signs and symptoms of alcohol or drug use, signs of acute drug or alcohol intoxication and with- drawal effects, drug tolerance effects, nega- tive consequences associated with substance abuse, the self-reported history of substance abuse, age and pattern of first substance abuse, recent patterns of use, drug(s) of

choice, and motivation for using substances. A full examination is made of the prior involvement in treatment, both in criminal justice and non–criminal-justice settings. Family history of substance abuse is also important, including current patterns of abuse by family members who have contact with the offender.

Screening instruments The effectiveness of substance abuse assess- ment and screening instruments may vary according to the criminal justice setting and the goals of gathering information in that set- ting. For example, in one study (Peters et al. 2000), eight different substance abuse screen- ing instruments were examined for use among male prisoners. Each of the instruments was found to have adequate test–retest reliability (the extent to which the scores are the same on two administrations of the instrument with the same people), although the validity of the instruments varied, as described later in this section. The screening instruments examined in the study included the following:

• Alcohol Dependence Scale (ADS)

• Addiction Severity Index (ASI)–Alcohol Use subscale (ASI-Alcohol)

• ASI–Drug Use subscale (ASI-Drug)

• Drug Abuse Screening Test (DAST-20)

• Michigan Alcoholism Screening Test (MAST short version)

• Substance Abuse Subtle Screening Inventory-2 (SASSI-2)

• Simple Screening Instrument for Substance Abuse (SSI-SA)

• TCU Drug Screen (TCUDS) (Knight et al. 2002)

However, these instruments varied consider- ably in sensitivity, specificity, and positive predictive value with different subpopulations (see appendix B for definitions of terms). For example, the SASSI-2 had significantly lower positive predictive value for African Ameri- cans than for Caucasians and Hispanics/ Latinos (Peters et al. 2000). Figure 2-3 lists

18 Chapter 2

recommendations for brief screening instru- ments based on this research (refer also to appendix C for the administration time and uses of specific instruments).

Findings indicated that either the TCUDS or a combination of the ADS and ASI-Drug screen should be used in situations in which it is important to reduce inappropriate referrals to substance abuse treatment. These instru- ments may be particularly useful for treat- ment programs that have limited “slots” available and significant consequences for mismatching offenders to the program (e.g.,

therapeutic communities or other residential programs). The SSI-SA is recommended for use in situations in which it is desirable to identify the largest number of offenders who need treatment (Peters et al. 2000). Some cor- rectional systems have begun to use the SSI- SA for initial screening at the time of prison admission, with conducting additional assess- ment later to verify the need for treatment and to determine the specific level of services needed.

In conducting screening and assessment with female offenders, counselors may want to

19

Figure 2-3 Recommended Substance Abuse Screening Instruments

Instrument Purpose Description

Alcohol Dependence Scale (ADS)

A 25-item instrument developed to screen for alcohol dependence symptoms; performs ade- quately in community and institutional settings

The ADS (Skinner and Horn 1984) can be coupled with the ASI-Drug Use section to provide an effective screen for alcohol and drug use problems among offenders. For more information on the ADS, contact the Center for Addiction and Mental Health (formerly the Addiction Research Foundation) at (800) 661-1111. The ASI is reprinted in TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994e).

Simple Screening Instrument for Substance Abuse (SSI-SA)

A 16-item screening instrument that examines symptoms of both alco- hol and drug dependence

An expert panel developed the SSI-SA as a tool for out- reach workers. The SSI-SA, which can be administered without training, includes items related to alcohol and drug use, preoccupation and loss of control, adverse conse- quences of use, problem recognition, and tolerance and withdrawal effects. The SSI-SA is fully described in TIP 11, Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases (CSAT 1994f) and is reproduced along with instructions in TIP 42, Substance Abuse Treatment for Persons With Co- Occurring Disorders (CSAT 2005c).

TCU Drug Screen (TCUDS)

A 15-item substance abuse diagnostic screen

The TCU Drug Screen is completed by the offender and serves to quickly identify individuals who report heavy drug use or dependency (based on the DSM-IV-TR and the National Institute of Mental Health Diagnostic Interview Schedule) and who therefore might be eligible for treat- ment. For more information regarding the TCUDS and other related instruments go to www.ibr.tcu.edu.

Source: Peters et al. 2000.

Screening and Assessment

consider use of the Alcohol Use Disorders Identification Test (AUDIT) and the Tolerance, Worried, Eye Openers, Amnesia, Kut Down test (TWEAK), both of which were developed for women and are more sensitive than the CAGE. The AUDIT and TWEAK also provide equivalent sensitivity in African Americans and Caucasians. For screening of alcohol problems among female offenders, counselors may also want to consider use of the Rapid Alcohol Problems Screen (RAPS), which has been shown to be more sensitive than other measures with African-American, Hispanic, and Caucasian women (Cherpitel 1997). See appendix C for information on how to obtain these instruments.

Assessment instruments A wide variety of substance abuse assessment instruments is available for use in the crimi- nal justice system. The most commonly used assessment instrument is the ASI (McLellan et al. 1980, 1992), which is used for screening, assessment, and treatment planning. The ASI was supported by the National Institute on Drug Abuse and is reproduced in TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (CSAT 1994e), and TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000c). The instrument provides a structured interview format to examine seven areas of functioning that are commonly affected by substance abuse, including drug/alcohol use, family/social relationships, employment/sup- port status, and mental health status. Many agencies, including those in criminal justice settings, have adapted modified versions of the ASI for use as a substance abuse screen- ing instrument. Two separate sections of the ASI that examine drug and alcohol use are frequently used as screening instruments.

A positive feature of the ASI is that it has been validated for use in criminal justice pop- ulations (McLellan et al. 1985, 1992; Peters et al. 2000). For example, the ASI is highly cor- related with objective indicators of addiction

severity. The ASI is also one of the few instru- ments that measure several different func- tional aspects of psychosocial functioning related to substance abuse and provide a con- cise estimate of the history of substance abuse as well as recent use. The instrument pro- vides severity ratings in each functional area assessed, which are useful both clinically and for research purposes. In using the ASI for assessment, significant training is needed to administer and score the instrument. The interview version of the ASI requires 45–75 minutes to administer, although the alcohol and drug use sections require considerably less time. A self-report version of the ASI was developed that has been shown to be a reli- able and accurate alternative to the coun- selor-administered instrument (Butler et al. 1998, 2001).

Detoxification Needs Screening should address current evidence of intoxication, dependence, overdose, and with- drawal. This is particularly relevant in com- munity corrections and jail settings, in which there may be significant periods of substance abuse that precede contact with the criminal justice system. Criminal justice and treatment staff should be trained to detect signs and symptoms of substance abuse and to refer clients to medical staff to assist in cases of acute intoxication. Once an individual is referred for detoxification, medical staff should perform a comprehensive assessment to determine the level of prior and recent use, and the level of substance abuse or depen- dence.

Safe withdrawal from substances such as stimulants, cocaine, hallucinogens, and inhalants can be achieved with psychological support, symptomatic treatment, and period- ic reassessments by healthcare providers. Frequent clinical assessments, along with appropriate treatment adjustments, are also important since the intensity of withdrawal cannot always be predicted accurately (Federal Bureau of Prisons 2000). Some sub- stances, such as alcohol, sedative-hypnotics,

20 Chapter 2

and anxiolytics, can produce dangerous with- drawal syndromes once physiological depen- dence has developed. Offenders who have severe and life-threatening symptoms of intoxication or withdrawal should be placed immediately under medical supervision. The Federal Bureau of Prisons (2000) recom- mends that “inmates presenting with alcohol intoxication should be presumed to have alcohol dependence until proven otherwise” (p. 8).

Not all substances of abuse produce clinically significant withdrawal syndromes, but absti- nence generally results in some psychological changes. Offenders should thus be reassessed often. Substance abuse may mask co-occur- ring mental disorders, such as depression, or symptoms of mental illness may disappear when the offender is not using. In some cases, withdrawal may cause symptoms of mental disorders that can be identified and treated.

For more information on the signs and symp- toms of intoxication and withdrawal and the treatment of individuals undergoing detoxifi- cation, see the forthcoming TIP Detoxification and Substance Abuse Treatment (CSAT in development a). The Federal Bureau of Prisons Clinical Practice Guidelines: Detoxification of Chemically Dependent Inmates, December, 2000 can be accessed online at www.nicic.org/pubs/ 2000/016554.pdf.

Physical Health Conditions Besides the potential need for detoxification services, screen- ing should also address signifi- cant medical conditions that may affect the offender’s involvement in treatment, such as physical disabilities, tubercu- losis, hepatitis, HIV/AIDS, and other debilitating diseases.

Readiness for Treatment In addition to examining the severity of sub- stance abuse problems, it is helpful to know whether a client is receptive to treatment and is committed to recovery goals. Readiness for treatment provides an important indicator regarding where the substance abuse treat- ment should begin.

Readiness for treatment is not always clearly defined or apparent at the onset of treatment. Most clients do not volunteer for treatment and experience significant ambivalence about the process and level of commitment required. For years, treatment professionals and paraprofessionals believed that a person needed to “hit bottom” to be ready for change. Today, it is recognized that people can be ready for treatment without “hitting bottom” and that many people can receive benefits from treatment even if they are not completely ready. For example, motivational interviewing (MI) techniques (discussed in detail in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999b]) can be used to help clients resolve their ambivalence toward treatment and toward making changes in their lives. MI pro- vides an empathic, supportive, and directive counseling style that attempts to persuade

21

Advice to the Counselor: Screening for Detoxification

• Screening forms should note evidence of intoxication, dependence, overdose, and withdrawal. This is particu- larly important in community corrections and jail set- tings, in which there may be significant periods of sub- stance abuse that precede contact with the criminal jus- tice system.

• Besides the potential need for detoxification services, screening should address conditions that may affect the offender’s involvement in treatment, such as physical dis- abilities.

• It is helpful to note whether a client is receptive to treat- ment and may be committed to recovery (readiness to change).

Screening and Assessment

and guide the client toward change rather than to create motivation through confronta- tion of the client’s substance abuse problems and labeling the client as an “addict.”

Many individuals who successfully recovered from substance abuse problems were coerced into treatment, either by family, employers, or the criminal justice system. Coerced treat- ment by the criminal justice system has been shown to be at least as effective as non- coerced treatment, when time in treatment is held constant (CSAT 1994a; De Leon 1988; Hubbard et al. 1988). Coercion can come from multiple sources. Many offenders reported that pressures from “psychological, financial, social, familial, and medical domains” had more influence in their decision to enter treatment than did the legal system (Marlowe et al. 1996, p. 81). However, their decision to stay in treatment is more often based on motivational readiness (Knight et al. 2000) and external leverage. Thus, for clients with low internal motivation, coercive inter- ventions may help to increase their readiness for treatment. Excluding people as “unready” or “unmotivated” would exclude the vast majority of clients and would mean that treat- ment and recovery would never begin for many (CSAT 1994a). For example, Alcoholics Anonymous counsels people who abuse alco- hol to “bring the body, and the mind will fol- low,” believing that motivational readiness will grow as the program takes hold.

An individual’s readiness for change is one of the most important factors that substance abuse counselors and clinicians should exam- ine during the screening and assessment pro- cess, and has been found to be predictive of treatment retention and other outcomes. Studies have shown that initial motivation for treatment influences enrollment in post- release treatment services (DeLeon et al. 2000; Simpson and Joe 1993). Several treat- ment interventions (e.g., MI, motivational enhancement therapy) (Miller and Rollnick 2002) have been developed to explore and enhance readiness for treatment. Many sub- stance abuse programs in the criminal justice

system include a “pre-treatment,” or “readi- ness” phase designed to address the needs of offenders not yet committed to recovery goals and ongoing involvement in treatment. This initial phase of treatment addresses offend- ers’ goals, expectations, and motivation for change. This intervention helps identify offenders who are ready for more intensive treatment services that require full participa- tion in activities designed to encourage changes in attitudes and behaviors.

Assessing readiness includes obtaining infor- mation about clients’ awareness of a sub- stance problem, their ability to acknowledge their need for help, their willingness to accept help, their perception of how others feel about their need for help, and whether they have taken steps to change on their own (Wanberg and Milkman 1998). Generally, clients can be considered “ready” for treat- ment if they want to abstain from substance abuse, see treatment as a means to become drug- or alcohol-free, and recognize the diffi- culty in abstaining from substance abuse without professional assistance (CSAT 1994a). Figure 2-4 describes several brief instruments that can be used to assess readi- ness for treatment. For more detailed infor- mation on this topic, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b). See also chapter 3 for a discussion of the stages of change model.

Co-Occurring Disorders A substantial percentage of those under crim- inal justice supervision have one or more co- occurring mental disorders in addition to their substance use disorder. There were an estimated 283,800 incarcerated individuals in 1998 who had a major mental disorder, including 16 percent of State prison inmates, 7 percent of Federal prison inmates, and 16 percent of jail inmates (Ditton 1999). Of all of these individuals, 49–65 percent were under the influence of drugs or alcohol at the time of their offense, and 24–38 percent had a his- tory of alcohol dependence. Because individu- als often require therapeutic intervention for

22 Chapter 2

co-occurring disorders, accurate screening and assessment are of particular importance.

Much of the literature related to co-occurring disorders in the criminal justice system has focused on the most severe mental disorders (e.g., schizophrenia, bipolar disorder, and major depression) (Broner et al. 2002). However, less severe disorders (e.g., anxiety, phobia disorders, and posttraumatic stress disorder [PTSD], along with less severe depression, attention deficit disorders, and various types of personality disorders) are also common among offenders with substance use and mental disorders, and can affect treatment outcomes (Broner et al. 2002; Haywood et al. 2000; Henderson 1998; Peters and Hills 1997, 1999; Teplin et al. 1996).

An important first step in treating offenders with co-occurring disorders is to develop a systematic approach to screen and assess for these disorders. Relatively few jurisdictions systematically screen for mental health prob- lems or co-occurring disorders upon arrest, prior to or following the arraignment process, or upon entrance into the jails. Despite the high prevalence of co-occurring disorders, these disorders are not always detected from the individual’s arrest charge or mental status during booking. Unless the screening process is systematic, the target population may not be identified. As a result, many individuals are not diverted into specialized programs or provided effective discharge planning— strategies that are likely to reduce recidivism (Broner et al. 2001a).

23

Figure 2-4 Instruments for Evaluating Readiness for Treatment

Instrument Description

The University of Rhode Island Change Assessment Scale (URICA)

URICA was developed to assess stage of change. The instrument is known to be valid with different populations in a variety of settings. El-Bassel and colleagues have deter- mined that URICA is useful, reliable, and valid among incarcerated women who use drugs (el-Bassel et al. 1998). The URICA and other similar instruments are reprinted in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b).

The TCU Treatment Motivation Scales

The TCU Treatment Motivation Scales can be used to track the stages of change in treatment motivation. For further information, go to www.ibr.tcu.edu.

The Circumstances, Motivation, Readiness, and Suitability Scales (CMRS)

The CMRS scales were designed to predict retention based on dynamic client factors related to seeking and remaining in treatment (DeLeon et al. 1994). The Circumstances scale is defined as the external pressure to engage and remain in treat- ment. The Motivation scale is defined as the internal pressure to change; the Readiness scale is defined as the perceived need for treatment; and the Suitability scale is defined as the individual’s perception of the treatment modality or setting as appropriate for himself. A prison version has been developed. A revised version of the CMRS, the CMR, is also available. The CMR is copyrighted and can be obtained by contacting the National Development and Research Institute, Inc., 71 W. 23rd Street, 8th Floor, New York, New York 10010, or [email protected].

Stages of Change, Readiness, and Treatment Eagerness Scale (SOCRATES)

SOCRATES includes items specifically focused on alcohol abuse and can be used as a starting point for discussion. A Spanish translation is available. The SOCRATES and other similar instruments are reprinted in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b).

Screening and Assessment

Screening and assessment for co-occurring disorders should occur soon after entry into involvement in the criminal justice system. Many individuals who are screened or assessed in court, community corrections, or jail settings may be under the influence of alcohol or drugs and may need to be detoxi- fied before determining whether they have co- occurring disorders. Acute symptoms of alco- hol or drug use and residual effects of detoxi- fication can mimic a wide variety of mental disorders, including anxiety, bipolar disor- der, depression, and schizophrenia. Most prison inmates screened for co-occurring dis- orders will have been detoxified by the time of admission to treatment, although chronic residual side effects of drug use may cloud the initial symptom picture. It is therefore impor- tant to identify patterns of recent substance abuse and to observe mental health symptoms over time to see if they resolve as the individ- ual detoxifies. It is often useful to defer diag- nosis (or to provide a provisional diagnosis, if needed) until the interactive effects of co- occurring disorders can be determined.

No single instrument can adequately screen for all mental and substance use disorders, particularly given the constraints of length, cost, and required training—but a combina- tion of instruments can be used (Peters and Hills 1999). The choice of substance abuse screening instruments should be based on the purpose of the screening, ethnic or racial characteristics, language spoken, and gender (Broner et al. 2002). Figure 2-5 provides a list and description of instruments used to screen and assess for mental disorders.

Broner and colleagues recommend the Mini- International Neuropsychiatric Interview for mental disorder screening in court-based diversion programs (without the Antisocial Personality Disorder and Substance and Alcohol Abuse modules and with a substance use rule-out question added to reduce false- positives). Several sources recommend the TCUDS, SSI, or ADS/ASI combination for substance abuse screening among offenders with mental health problems (Broner et al. 2001a; Peters and Bartoi 1997). For assess- ment of psychiatric disorders, Broner and

24

Steps for Assessing the Interactive Effects of Co-Occurring Disorders

1. Assess the significance of the substance use disorder. Obtain a chronological history describing the onset of mental disorder and substance abuse symptoms.

•Determine whether mental disorder symptoms occur only in the context of substance abuse.

•Determine whether ongoing abstinence leads to rapid and full resolution of mental disorder symptoms.

2. Determine the duration of the current period of abstinence.

•If there has not been a 4–6 week period of abstinence, repeat assessment and diagnosis after such a period, depending on clinical judgment about the particular drug abuse history and the offender’s physical status.

3. Reassess mental disorder symptoms at the end of 4–6 weeks of abstinence or at any time such symptoms appear or change.

4. If mental disorder symptoms are fully resolved, consider referral for traditional substance abuse treat- ment; if not, consider referral for mental health or specialized co-occurring disorders services.

5. Provide ongoing reevaluation of the offender’s mental disorder symptoms and progress in treatment.

Chapter 2

25

Figure 2-5 Instruments for Screening and Assessing Mental Disorders

Instrument Description

Beck Depression Inventory II (BDI-II)

(Beck et al. 1996)

• A 21-item self-report of symptoms that screens for symptoms of depression.

• Requires no significant training to administer.

• Found to be the most effective instrument in detecting depression among individu- als who abuse alcohol (Weiss and Mirin 1989).

• Should not be used as a sole indicator of depression but in conjunction with other instruments (Weiss and Mirin 1989; Willenbring 1986).

Brief Symptom Inventory (BSI)

(Derogatis 1975a)

• A short form of the Symptom Checklist 90 - Revised (SCL-90-R).

• Comprising 53 items, including three global indices of psychopathology (General Severity Index, Positive Symptom Total, Positive Symptom Distress Index) and nine primary psychiatric symptom dimensions.

• Quick to administer and requires no significant training to administer.

• Only a 6th grade reading level is required.

• May be most useful as a general indicator of psychopathology (Boulet and Boss 1991).

General Behavior Inventory (GBI)

(Depue and Klein 1988)

• A 73-item self-report instrument that examines mood disorders.

• Requires no significant training to administer.

• Differentiates between unipolar and bipolar depression.

Hamilton Depression Scale (HAM-D)

(Hamilton 1960)

• A 17-item scale completed by an interviewer based on self-report information.

• Examines several key elements of depression, including sleep disturbance, somati- zation, anxiety-depression, and apathy.

• Requires training to administer.

Mental Health Screening Form-III (MHSF-III)

(Carroll and McGinley 2001)

• Eighteen simple questions designed to screen for present or past symptoms of most of the main mental disorders.

• A “rough” screening device and asks only one question for each disorder for which it attempts to screen.

• Reproduced in TIP 42, Substance Abuse Treatment for Persons With Co- Occurring Disorders (CSAT 2005c).

Millon Clinical Multiaxial Inventory (MCMI-III)

(Millon 1983; Millon et al. 1994)

• A self-report measure with several subscales.

• Useful in assessing Axis II (personality) disorders that may affect involvement in treatment.

• Includes the Drug Abuse Scale (DAS), an instrument designed to measure person- ality characteristics often associated with drug abuse (Calsyn and Saxon 1989).

Screening and Assessment

colleagues recommend the Structured Clinical Interview for DSM-IV (SCID) (Broner et al. 2001a). Refer to appendix C for these and other examples of instruments that are rec- ommended for use with specific populations. For more information on screening for co- occurring disorders see chapter 4 of TIP 42,

Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c).

History of Trauma Rates of trauma in men and women entering the criminal justice system are higher than are rates found in community samples. For

26

Figure 2-5 (continued) Instruments for Screening and Assessing Mental Disorders

Instrument Description

Minnesota Multiphasic Personality Inventory (MMPI-2)

(Butcher et al. 2001)

• A self-report measure with 567 items, 10 main clinical scales, and 10 supplementary scales.

• A restandardized version of the MMPI.

• Frequently used in correctional settings for classification and assignment to housing or inmate programs, and to predict an inmate’s response to placement in a correc- tional setting.

• Useful in identifying characteristics of antisocial personality disorder.

• Designed to identify psychopathology and not to identify substance use disorders.

Personality Assessment Inventory (PAI)

(Morey 1991)

• A self-report measure with 344 items and 22 scales.

• Eleven clinical scales include separate measures of alcohol problems and drug problems.

• Five treatment scales are also provided in the PAI.

Referral Decision Scale (RDS)

(Teplin and Swartz 1989)

• A 14-item measure of mental disorder symptoms developed to identify mental health problems.

• Developed and validated in a criminal justice setting.

• Found to be useful in detecting the presence of major mental illness among jail inmates.

• Requires no training to administer.

• Self-administered.

• Examines only a few mental disorders (depression, bipolar disorder, schizophrenia).

Symptom Checklist 90 - Revised (SCL-90-R)

(Derogatis 1975b)

• A 90-item, multidimensional self-report inventory designed to assess recently experi- enced physical and psychological distress.

• Requires no training to administer.

• Self-administered.

• Short amount of time to administer.

• Frequently used in criminal justice settings.

• Covers a wide range of symptom dimensions that include somatization, obsessive- compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.

Chapter 2

example, Teplin et al. (1996) found that 34 percent of female jail inmates had PTSD. According to the DSM-IV-TR, trauma is defined by two characteristics:

1. A person experiences, witnesses, or is threatened by physical harm.

2. The person’s response to the event includes “intense fear, helplessness or horror” (APA 2000a, p. 463).

This definition highlights that trauma is not simply an event of a particular type but includes a subjective dimension in that the per- son’s response to the event is powerfully nega- tive. For example, one person may survive a car accident and not react with “fear, helpless- ness, or horror,” while another person does experience such feelings.

Among female State prisoners, 40–80 percent report a history of emotional, physical, or sexual abuse (Bloom et al. 1994; Snell 1994). Female prison inmates are three times more likely to report a history of any abuse and six times more likely to report a history of sexual abuse in comparison to male inmates. A histo- ry of physical or sexual abuse has been linked to many types of mental disorders, including PTSD, depression and suicidal behavior, and borderline personality disorder and other personality disorders (Spielvogel and Floyd 1997).

Despite high rates of physical and sexual abuse among offend- ers, screening and assessment in the criminal justice system has not historically addressed these issues, nor have treatment ser- vices been provided in jail, prison, or community settings. There are many compelling rea- sons to address abuse and trau- ma issues during screening and assessment in the criminal justice system. For many offenders, the guilt, shame, and low self-esteem related to their trauma history may lead to social isolation and

may reduce participation in treatment activi- ties. For example, given the close relationship between past physical or sexual abuse and substance abuse, treatment that does not address one of the “root” contributors to sub- stance abuse may be perceived as unimpor- tant or irrelevant and may not provide suffi- cient incentives for the offender to change his or her attitudes and behavior. The offender’s resulting lack of engagement in program ser- vices may be misinterpreted as resistance to treatment or lack of motivation rather than to psychological issues related to abuse and trauma. Forced abstinence during jail or prison may also deprive offenders of their primary means of coping with negative emo- tions related to past abuse and trauma (i.e., use of drugs and alcohol). When this coping mechanism is no longer available, many offenders are left vulnerable and may begin to exhibit symptoms of depression and other mental disorders that can interfere with treat- ment. If unaddressed, past trauma can also trigger substance abuse relapse (during or after treatment), through emotional, physical, or situational cues associated with prior abuse experiences.

Only trained counselors should inquire about abuse and trauma issues. The counselor should be prepared for how to respond to self-disclosed experiences related to physical and sexual abuse and how to provide referral for services. In most substance abuse settings,

27

Advice to the Counselor: Screening for Co-Occurring Disorders • Screening and assessment for co-occurring disorders

should occur on entry into the criminal justice system, given the high prevalence of co-occurring disorders in this population.

• Individuals in community corrections or jail settings may need to be detoxified before screening for co-occurring disorders. The acute symptoms of alcohol or drug use and the residual effects of detoxification can mimic a wide variety of mental disorders, including anxiety, bipo- lar disorder, depression, and schizophrenia.

Screening and Assessment

the goal of screening or an intake interview is not to compile detailed and comprehensive information regarding past trauma, but to identify that the offender has a history of trauma for purposes of treatment planning, triage, and referral for more intensive ser- vices. As a result, counselors should be famil- iar with and have ready access to resources (e.g., counselors with mental health training, liaisons from women’s shelters and treatment programs) to refer persons who wish to dis- cuss their histories of trauma in more detail.

Although clinicians are sometimes concerned about addressing material that is potentially uncomfortable or even overwhelming for either the client or themselves, these adverse consequences are rarely experienced when these issues are raised by well-trained staff. In fact, offenders are typically relieved to talk frankly about their abuse and trauma experience, albeit in an appropriately limited fashion. Indepth discussion of the specific events surrounding traumatic experiences is typically conducted in followup individual or

28

Screening and Assessment of Abuse and Trauma History

Structured interview assessments • Trauma Assessment & Treatment Resource Book

New York State Office of Mental Health’s Trauma Initiative Design Center 44 Holland Ave Albany, NY 12229 Fax requests: (518) 473-2684

• The Integrated Biopsychosocial Assessment that includes trauma history questions in an assessment form appropriate for a mental health or substance abuse setting. Available from:

Colleen Clark, Ph.D. Louis de la Parte Florida Mental Health Institute 13301 Bruce B. Downs Blvd./ MHC 1345 Tampa, FL 33612-3899 Requests by e-mail: Cclark@ fmhi.usf.edu

Self-report instruments • The Traumatic Antecedent Questionnaire (TAQ) (van der Kolk 1992). A widely used measure of lifetime

experiences of trauma in 10 domains, i.e., physical, sexual, witnessing trauma, etc.

• The Dissociative Experiences Scale (DES) (Bernstein and Putnam 1986). A self-report measure examining several domains of dissociative phenomena, often sequelae of trauma, i.e., amnesia, identity alterations, spontaneous trance states, etc.

• The Clinician Administered PTSD Scale (CAPS) (Blake et al. 1998). A clinician-administered scale that provides an accurate diagnosis of PTSD.

• The Trauma Symptom Inventory (TSI) (Briere 1995). A 100-item self-report instrument that evaluates symptoms in adults that may have arisen from childhood or adult traumatic experiences. Includes 10 clin- ical scales and 3 validity scales. An alternate version (TSI-A) includes no references to sexual issues. The companion Trauma Symptom Checklist 40 (Briere 1995; Briere and Runtz 1989) is a 40-item instrument that contains 6 sub-scales. Items are rated on a 4-point scale covering frequency over the past 2 months.

• Posttraumatic Disorder Scale (PTDS) (Foa et al. 1993). Measures trauma history and specific symptoms associated with posttraumatic stress disorder.

Chapter 2

group treatment sessions that specifically address this topic area. Treatment for trauma issues progresses in stages, with early treat- ment goals focused on issues of ensuring safe- ty in relationships, the place of residence, and in the workplace. Later work explores issues of recovery and reconciliation, if appropriate. This later work is frequently conducted by therapists with advanced degrees and in most cases is not appropriately addressed by paraprofessional staff.

Most commonly, assessment of trauma has been conducted through a clinical interview. In these settings, it is preferable to use stan- dardized questions that avoid the use of terms such as “abuse,” “trauma,” or “perpetrator” and that instead focus on description of spe- cific events or experiences.

Sample interview questions could include:

• Were you ever hit or punished in ways that left bruises, burns, or cuts? Were you ever threatened with knives or guns? Were you ever made to go without eating? Did you ever witness anyone else getting hurt? Did you ever have to be taken from your parents’ care?

• As a child, did you have any sexual experi- ences? With whom and for how long did this go on? Were you ever threatened about it? Were any photos taken? Did any of these experiences lead to medical or other prob- lems? Do you have any recur- rent memories of these events now?

• Are you safe in your current relationship? Has your safety ever been threatened in any of your adult relationships? Have you been punched, shoved, or hit? Did you ever seek any medical help as a result? Have you talked to people about these experiences? (Spielvogel and Floyd 1997).

For more information on this topic see also TIP 25, Substance Abuse Treatment and Domestic

Violence (CSAT 1997b), TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000d), and the forthcoming TIP Substance Abuse and Trauma (CSAT in development f).

Psychopathy and Risk for Violence and Recidivism A number of criminogenic “risk factors” are often assessed in justice settings to determine eligibility for admission to substance abuse treatment programs and community release (e.g., parole), and for placement in institu- tional housing or in different levels of super- vision (Borum 1996; Douglas and Webster 1999; Otto 2000). This information is particu- larly helpful to identify offenders likely to be disruptive in treatment programs, to be re- arrested, or to commit violent crimes after release from institutions. Risk factors can be categorized as static or dynamic. Static risk factors are those that cannot change, such as gender and race, or are relatively enduring traits such as the diagnosis of a mental disor- der, criminal history, family history, and the characteristics of the offender’s victims. Dynamic risk factors are those likely to change over time and that change according to the client’s environment, social situation, or experiences, such as drug use or homeless- ness. Following is a discussion of the risk fac-

29

Advice to the Counselor: Screening for Trauma

• Trained counselors are best equipped to inquire about abuse and trauma issues. Offenders who have experi- enced abuse or trauma and who are undergoing forced abstinence while in jail or prison may be deprived of their primary means of coping with the negative emo- tions related to past trauma. These offenders may begin to exhibit signs of depression or other mental disorders that can interfere with treatment.

• Counselors should be familiar with and have ready access to resources to refer persons who wish to discuss their histories of trauma in more detail.

Screening and Assessment

tors for psychopathy and for violence and recidivism.

Psychopathy One stable risk factor often found among offenders with substance use disorders is psy- chopathy and the closely related antisocial personality disorder defined in the DSM-IV classification system. Personality disorders are persistent and pervasive patterns of mal- adaptive behavior that are usually exhibited early in life. Historically, many terms have been used to describe personality disorders that involve criminogenic characteristics. Four closely linked terms are “sociopath” (and the trait of sociopathy), “antisocial per- sonality” (and antisocial traits), “dissocial personality” (dissocial behavioral traits), and “psychopathic personality disorder” (psy- chopathy or psychopathic traits). Whereas the first three formulations of criminogenic personality types focus on social deficits and mild emotional and cognitive problems result- ing in impulsivity and poor school achieve- ment, psychopathy focuses on primary and severe deficits in attachment and interperson- al bonding, lack of empathy for others’ expe- riences, lack of remorse, and shallow emo- tional functioning. These relatively stable traits are thought to have a biological basis. As previously indicated, psychopathy is relat- ed to the DSM-IV antisocial personality disor- der but represents a more extreme version of that disorder. Some would argue that psy- chopathy represents a distinct diagnostic group. From 40 to 60 percent of male prison

inmates meet the criteria for antisocial per- sonality disorder, whereas only 10 to 20 per- cent of male prison inmates meet the criteria for psychopathy (Hare et al. 1991).

Psychopathy is an important predictor of treatment dropout, level of involvement in violence, and criminal justice recidivism (Hart et al. 1994; Hemphill et al. 1998; Ogloff et al. 1990; Rice et al. 1992). Offenders iden- tified as having a high degree of psychopathy may require specialized, more structured treatment approaches, although there is not a large body of evidence describing effective therapeutic interventions that have been applied to this population. Assessment for psychopathy is often used in criminal justice settings to rule out individuals for treatment involvement, particularly if there are not suf- ficiently structured treatment programs avail- able.

Few short screening instruments exist for psy- chopathy because of the complexity of dimen- sions that need to be examined. The most widely used instrument to identify psychopa- thy is the Hare Psychopathy Checklist- Revised (PCL-R) (Hare 1998b; Hare et al. 1991; Hart et al. 1994). The PCL-R is consid- ered the “gold standard” for measuring psy- chopathy. It requires a significant amount of time to review archival information and to conduct an interview. A shorter screening version of this instrument—the PCL-SV—has also been developed for use with this popula- tion and validated in substance abuse treat- ment settings (Hart et al. 1995). Another shorter (60-item) measure, the Self-Report

Psychopathy (SRP) instrument, has been developed for use in criminal justice settings by the author of the PCL-R.

Several other short self-report screening instruments for psy- chopathy have been developed but have yet to be fully validated with criminal justice popula- tions. These include the Psychopathic Personality

30

Advice to the Counselor: Screening for Psychopathy

• Psychopathy is an important predictor of treatment dropout, level of involvement in violence, and criminal justice recidivism. Offenders identified as having a high degree of psychopathy may require specialized, more structured treatment approaches, although there is not a large body of evidence describing effective therapeutic interventions for this population.

Chapter 2

Inventory (Lilienfeld and Andrews 1996), the Psychopathy Q-Sort (Reise and Oliver 1994; Reise and Wink 1995), and the Levenson Self- Report Psychopathy Scale (Brinkley et al. 2001; Levenson et al. 1995). A number of other screening and assessment instruments examine personality features related, but not identical, to psychopathy (Zimmerman 2000), as described in Figure 2-6 on the next page.

Violence and recidivism Although psychopathy may be the single most important risk factor for criminal recidivism, other risk factors are important to assess among offenders with substance abuse prob- lems. Even offenders determined to have low levels of psychopathy may still be at high risk for violence or recidivism due to other risk factors. Other major risk factors for violence and criminal recidivism include

• Antisocial attitudes

• Criminal peers

• Prior history of crime and violence, and early age at time of first offense/violent act

• Active symptoms of severe mental illness

• Impulsivity

• Environmental stress

• Treatment nonadherence

• Personality disorders (generally)

A number of environmental stressors can lead to renewed substance use and risk for recidi- vism when offenders are released from cus- tody or when their daily structure and level of supervision is reduced (Peters 1993; Wanberg and Milkman 1998). During these transitions, many offenders face employment and financial problems, and few have family or social supports. Meanwhile, there are immediate demands to organize daily activi- ties, develop and maintain constructive rela- tionships, manage personal or household finances and problems, and participate in community supervision. Many offenders involved with drugs have never learned the requisite skills to accomplish these tasks, and

some rapidly return to substance abuse in the absence of opportunities to learn and rehearse those skills.

Many offenders have long histories of psy- chosocial problems that have contributed to their substance abuse and criminal involve- ment. These include interpersonal difficulties with family members, difficulties in sustaining long-term relationships, emotional and psy- chological difficulties, difficulties in managing anger and stress, educational and vocational skills deficits, and employment problems (Belenko and Peugh 1998; Peters 1993). Offenders do not typically plan or seek out addictive lifestyles or relapse. Rather, it is their lack of planning, personal objectives, and self-monitoring that leads to substance abuse or dependence or relapse. The lack of basic coping skills to manage life and social pressures further contributes to the risk for relapse and recidivism.

Reunification with family members is often accompanied by stress related to the family’s distrust and anger over offenders’ past drug use, unresolved conflicts with the partner or spouse, shifting parental roles, and added financial obligations, as well as drug use in the family or neighborhood. Elements of com- munity supervision can also increase an offender’s stress during re-entry to the com- munity. These include drug testing, use of house arrest, and other surveillance or reporting activities, as well as the offender’s recognition of the significant level of effort and adherence required by community super- vision programs. The community’s ongoing leverage to maintain the offender’s involve- ment in treatment following release from cus- tody or other secure settings can be a further stressor (U.S. Department of Justice 1991). Figure 2-6 (next page) provides descriptions of three general assessment instruments relat- ed to the risk for violence and recidivism.

31Screening and Assessment

32 Chapter 2

Figure 2-6 Instruments Examining Psychopathy and Risk for

Violence and Recidivism

Instruments Description

Psychopathy assessment instruments

Psychopathy Checklist – Revised (PCL-R)

•A 20-item assessment measure that requires use of a semi-structured interview and review of archival records.

•Requires 90–120 minutes for the interview section and 60 minutes for the collateral records review.

•Measures the extent to which individuals exhibit psychopathic features on a 40-point scale, with a cutoff score of approximately 30 indicating psychopathy.

•Has considerable validation for use with offenders and is highly predic- tive of violence and criminal recidivism.

Psychopathy Checklist – Screening Version (PCL-SV)

•A 12-item measure examining the same construct of psychopathy as the PCL-R.

•Requires 45 minutes for the interview section and 30 minutes for the col- lateral records review.

•Scored on a 24-point scale with a cutoff of approximately 18 indicating psychopathy.

Other instru- ments related to psychopathy

Carlton Psychological Survey

•Used as an intake screening in correctional settings. •Contains scale scores for five categories: antisocial tendencies, chemical

abuse, self-depreciation, thought disturbance, and validity. •Especially useful for those with low education and literacy as it requires

only a 4th-grade reading level.

Jesness Inventory • Examines moral development throughout the life span.

Paulus Deception Scales

• Gauges the extent of deception provided through offenders’ self-report.

Millon Clinical Multi-Axial Inventory-III (MCMI-III)

• Provides an assessment of personality disorders and psychopathy. • Correctional version of the MCMI-III provides early identification of

substance abuse and mental health problems. • The 175-question test takes 25 minutes to complete. • Spanish versions available (Millon et al. 2002).

Minnesota Multiphasic Personality Inventory (MMPI-2)

• A self-report objective assessment measure with 567 items, 10 main clini- cal scales, and 10 supplementary scales (Hathaway and McKinley 1989).

• The Psychopathic Deviate Scale on the MMPI identifies individuals with psychopathic and antisocial features.

• Frequently used in criminal justice settings (particularly in prisons) for classification and assignment to housing or offender programs and to predict an offender’s response to placement in prison setting.

• MMPI subtypes described by Megargee et al. (1979) are often used to identify offenders who require more intensive supervision and struc- tured program activities.

Selection and Implementation of Instruments Using well-accepted and standardized instru- ments can bring uniformity, quality control, and structure to the process. Some instru-

ments may be more appropriate than others for particular purposes (CSAT 1994a), depending on the information needed for treatment decisions. For example, some instruments focus on drug dependence and not abuse, some identify those for whom spe- cific treatment options are appropriate, and

33

Figure 2-6 (continued) Instruments Examining Psychopathy and Risk for

Violence and Recidivism

Instruments Description

Other instru- ments related to psychopathy

Personality Assessment Instrument (PAI)

• Self-report instrument for assessing traits associated with psychopathy.

• Includes 344 items and requires 50–60 minutes to administer.

• Contains scales for Negative Impression Management, Malingering, and Defensiveness (Morey and Lanier 1998).

• The Antisocial Features (ANT) scale is the most highly correlated with psychopathy and focuses on antisocial behaviors, egocentricity, and stimulation-seeking.

General assessment instruments related to the risk for vio- lence and recidivism

Level of Service Inventory (LSI) - Revised

•A 54-point scale used to predict the chances of criminal recidivism or supervision failure among offenders.

•Useful for identifying those in need of more intensive levels of treatment, placement in halfway houses, and level of supervision and security clas- sification (Andrews and Bonta 1995).

•Used by jurisdictions to support an increase or decrease in the level of community supervision.

•Includes assessment of drug use and is sometimes used in tandem with substance abuse treatment decisions.

Historical, Clinical, Risk Management (HCR-20)

•Provides a comprehensive risk assessment based on historical, clinical, and risk management assessments.

•Composed of static and dynamic factors with information derived from clinical interview, standardized assessment (e.g., the PCL-R or PCL- SV), and collateral sources.

• Includes three sections—10 historical items, 5 clinical items, and 5 risk management items—with a final risk rating of low, medium, or high (Webster et al. 1997, 2000).

The Violence Risk Appraisal Guide (VRAG) (Harris et al. 1993)

•An assessment tool for predicting violent recidivism.

•Is an actuarial measure based on 12 objective variables that are linked to recidivism.

•Requires interview and archival review, and incorporates results of diag- nostic testing, IQ testing, the PCL-R, criminal history, and indicators of adult adjustment.

Screening and Assessment

some are validated for use with criminal jus- tice populations.

The appropriateness of particular instru- ments depends on the type of client being referred to a specific criminal justice program and the goals related to program admission. For instance, drug education programs are generally provided to a wide number of offenders, and a substance abuse screen that tends to be overly inclusive for this interven- tion might be preferred to a more exclusive screen. On the other hand, because of the limited access to treatment for offenders with co-occurring substance use and mental disor- ders, screening for mental disorders as well as for drug use problems may need to be conser- vative to avoid referring someone who does not need services. Therefore, flexibility in developing screening and assessment approaches is needed, depending on specific program parameters (e.g., type of staff, client goals and needs).

This section describes the various factors that the consensus panel thinks are important in the selection of screening and assessment instruments, including length, cost, window of detection, interview versus self-administered instruments, staff training required, literacy, language, and computerization.

What Guidelines Are Available Regarding the Effectiveness of Instruments? Screening and assessment instruments vary considerably in their ability to detect sub- stance use disorders and in the coverage of related areas such as mental health and other health issues, family and social functioning, and employment. The consensus panel believes that several guidelines should be con- sidered when selecting substance abuse instruments for a particular criminal justice setting, in addition to the time and cost of administration. These guidelines, also known as “psychometric properties,” are often described in research reports examining a particular instrument or in manuals that

accompany the instruments. Five major sta- tistical guidelines are used to gauge an instru- ment’s accuracy for use with client popula- tions:

• Overall accuracy—the extent to which the instrument classifies respondents correctly.

• Sensitivity—the extent to which the instru- ment accurately identifies those with sub- stance use disorders (true positives).

• Specificity—the extent to which the instru- ment accurately identifies those without substance use disorders (true negatives).

• Positive predictive value—the proportion of offenders identified by the instrument as having substance abuse problems, com- pared to the total number having substance abuse problems.

• Negative predictive value—the proportion of offenders identified by the instrument as not having substance abuse problems, com- pared to the total number not having sub- stance abuse problems.

Psychometric information helps counselors decide the usefulness of a screening instrument in a specific criminal justice setting. Questions counselors should ask include

• Are there normative scores for the popula- tion?

• Does the research show the instrument is valid for use with offenders and for rele- vant ethnic/cultural groups represented?

• Is it better to err on the side of false- positive or false-negative results? In other words, a decision must be made about whether to err on the side of sending some- one to treatment who does not need it or not sending someone who does need it.

Length Another critical factor that enters into the choice of a substance abuse screening instru- ment is how long it takes to administer. Although many drug use assessments are well designed and serve as broad sorting tools for treatment and intervention, they tend to take longer to administer than correctional agen-

34 Chapter 2

cies can afford (Knight et al. 2002). Rather, correctional systems usually have a short period of time to determine which of a large number of offenders need treatment. For example, the Program and Services Division of the Texas Department of Criminal Justice coordinates a drug abuse screening and treat- ment referral process for several hundred inmates monthly. The division lacks the staff, time, or financial resources to administer lengthy individual interviews for each new admission. Therefore, simple logic dictates that an instrument should not be used if it takes longer to administer than the staff time available.

Cost The cost of instruments varies according to whether they are publicly or commercially available, whether the instrument is computer- ized, and the unit costs per administration that are assigned by the publisher. There are sever- al screening and assessment instruments avail- able at no cost in the public domain. Other commercially available instruments are avail- able that can often be administered for $1 to $5 per unit. (See appendix C.)

Window of Detection Questions phrased to ask about a relatively short window of detection—focusing on current rather than lifetime alcohol and drug prob- lems—are recommended for screening (Cherpitel 1997; Knight et al. 2002) because there is a greater chance of obtaining valid responses. However, shorter detection windows could be too restrictive, and some who need treatment could be overlooked (e.g., offenders who abstained from substances while awaiting trial).

Interview Versus Self- Administered Instruments The method used to administer an assessment instrument has implications for staffing, lan- guage, literacy, and reading level. A face-to-

face interview can ensure that the respondent understands the items and answers them, but it is more time consuming and costly. The interview, which may be broken into several sessions, might be more appropriate for those with physical or cognitive disabilities. If cost is a concern, self-administered instruments could be used. Use of small-group interviews is another less costly alternative to individual interviews (Broome et al. 1996b).

Research suggests that the reliability of the administration method varies by setting and the con- tent evaluated (Broner et al. 2002; Broome et al. 1996b; Knight et al. 1998). The method chosen (e.g., interview or self-administered) also affects the amount of training required to adminis- ter the screening.

Staff Training Required Training will have a major impact on instru- ment selection. Logically, if resources for intensive training are not available, instru- ments should be selected that do not require interpretation. Although most screening instruments do not require substantial staff training, some, such as the SASSI, may require more training than others. Further, even when little training is required, such as for the CAGE or interview-based instru- ments, the level of training can influence the validity of results. For assessment instru- ments such as the ASI, training may have a significant impact on the interpretation of results, administration of the instrument, and development of basic counseling techniques related to engaging clients, eliciting problems, interviewing strategies, and dealing with resis- tance.

35Screening and Assessment

Correctional staff

members who

have been trained

to administer an

instrument can, in

turn, train others

to use it.

Even with qualified staff, extensive training may be difficult to implement. Choosing a brief, easily administered screening instru- ment that requires little staff training can solve these difficulties. In some instances, correctional staff members who have been trained to administer an instrument can, in turn, train others to use it (Knight et al. 2002).

Literacy A brief screening for literacy is recommended if it is suspected that a client may not be able to complete a paper-and-pencil test. The Slosson Oral Reading Test–Revised (www.slosson.com) may be useful if a coun- selor wants to know whether a client can read at a particular grade level. It is important to note, however, that a client’s inability to read or write does not mean he or she cannot take an active part in the assessment. Rather, the counselor can substitute an interview for a paper-and-pencil assessment and a thumbprint for a signature.

Language Optimally, the instrument chosen should be written in the individual’s language of choice, whether English or another language. However, it should not be assumed that indi- viduals who can speak a particular language can also read that language, or any other. To that end, the client may need to communicate in “street language.” In this case, the coun- selor should mirror and leverage whatever vocabulary the client uses. Professional or clinical jargon should be avoided (CSAT 1994a).

Translating an instrument on the fly, such as for the Hispanic/Latino population, will greatly reduce the reliability and validity of screening results. Each population has differ- ent usages of language; misunderstandings and inaccuracies can impact engagement in treatment and client motivation for change.

Computerization Some instruments allow screening through computerization (e.g., ASI). Computerization can reduce the personnel time needed to con- duct screening and assessment but can also reduce the comprehensiveness of information gathered compared to clinical interviews. Research indicates that a computerized ver- sion of the ASI provides good reliability and validity for use with substance-involved clients (Butler et al. 1998, 2001). One report (Budman 2002) concluded that the computer- ized ASI is “more reliable, faster to adminis- ter, more accepted by patients, and more cost-effective” in comparison to the interview version of the ASI. While computerization can decrease the effort and time required for scoring, it can be an obstacle for offenders who are unfamiliar with computer technology and introduces added up-front and ongoing costs.

Screening and Assessment Considerations for Specific Populations Within different treatment settings in the criminal justice system, screening and assess- ment instruments and procedures are some- times altered to address the unique needs of specific clinical populations, such as ethnic and cultural minorities, women, and offend- ers with co-occurring disorders. For example, there is a growing recognition that instru- ments vary in their ability to detect substance abuse and other problems among these specif- ic populations and that in some cases new instruments need to be developed. A related concern is that if a screening or assessment instrument is substantially modified for use with specific populations, research is needed to validate the effectiveness of the new instru- ment in that setting. Another concern is that if items are added or deleted, this may affect

36 Chapter 2

the overall scoring of the instrument. The fol- lowing section presents issues to consider when screening and assessing specific popula- tions and suggests strategies for modifications to instruments and procedures.

Racial and Ethnic Minorities When the counselor and the offender are from different racial or ethnic groups, the potential for misunderstanding is consider- able. These differences can affect the staff’s ability to assess client needs and/or to recom- mend culturally competent services for clients from other cultures and can jeopardize the client’s chances for treatment success. The sources of misunderstanding originate in cul- ture, socioeconomic class, and language (Sue and Sue 1999), as well as in race, gender (Broner et al. 2001a), literacy, and physical or cognitive inability to respond to the instru- ment (CSAT 1994a).

A general introduction to a screening or assessment could include statements about the effects of substance abuse on society or on the client’s culture, along with information about the purpose of the process. Counselors should ask clients directly about how they view or describe themselves and their preferred usage of terms such as black, African American, person of color, Hispanic, Latino, Chicana, Pacific Islander, gay, homosexual, or lesbian. Counselors should also be aware of general cultural beliefs and expectations. For exam- ple, screening American-Indian populations can prove difficult because gaining trust is sometimes a challenge. Moreover, some tribal cultures dictate silence about substance abuse issues. As a result, a screening that detects the need for further assessment brings the stigma of losing dignity in the tribe. American-Indian men and women may also be the victims of other types of abuse that can impede the screening and assessment process. Further barriers of language, literacy, and comprehension are also present in this popu- lation (Sue and Sue 1999).

It may be necessary for a counselor to modify screening and assessment instruments to be sensitive to cultural differences. Individuals interested in modifying instruments should consult the research literature to identify adaptations that have already been developed and validated or new scales that have been adapted for the instruments. For example, several adaptations of the ASI have been developed for use with American Indians (Carise et al. 1998) and with women (CSAT 1997c). Also, new intake and followup scales have been developed for the ASI (Alterman et al. 1998). Counselors are encouraged to determine whether norms for an instru- ment make sense with the population they are testing. If the recognized crite- rion score results in too many individuals being excluded from treatment, perhaps the counselor should consider lowering it. (See also the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development b].)

Women Counselors also need to be aware of special issues in screening and assessing female offenders. Women respond differently to the screening process than men (Kassebaum 1999), and a longer, more flexible format is often useful, particularly to explore unantici- pated areas that may arise. Females are more likely than males to have a co-occurring men- tal disorder and trauma-related problems. In addition, they are more likely to be affected by poverty, abuse histories, unstable social supports, and medical problems (el-Bassel et al. 1996; Fullilove et al. 1993; Haywood et al.

37Screening and Assessment

Women respond

differently to the

screening process

than men, and a

longer, more

flexible format is

often useful.

2000; Henderson 1998; Jacobson and Herald 1990; Jordan et al. 1996; Richie and Johnsen 1996; Teplin et al. 1996). In addition, many have lost custody of their children as a result of incarceration. Important counseling and treatment approaches for women are described in CSAT’s Technical Assistance Publication (TAP) 23, Substance Abuse Treatment for Women Offenders: Guide to Promising Practices (Kassebaum 1999), and the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development g). Additional guidelines for screening and assessment of trauma history among female offenders are discussed earlier in this chapter.

Most substance abuse screening and assess- ment instruments were developed and tested in male populations. Those working with female offenders should carefully review screening and assessment instruments to examine whether they have included content that is relevant to female offenders, such as information related to custody of children and parenting, history of physical and sexual abuse, and symptoms of trauma. Test instru- ments should be examined to determine if they were developed and normed using female populations, and if not, whether there are other instruments that may be more suitable

for this population. One example of an instru- ment that has been tested with both male and female populations is the TCUDS II, which has been found to have good reliability for both genders (Knight 2001). Other screening instruments such as TWEAK have been developed specifically for women.

Offenders With Co-Occurring Mental Disorders As noted previously, specialized screening and assessment approaches are needed for offenders with co-occurring disorders. Integrated screening and assessment approaches should be used to determine the scope, symptoms, and consequences (e.g., level of cognitive and intellectual functioning) of mental and substance use disorders and to examine the relationship between these disor- ders and criminal behavior. Because of the high rates of co-occurring disorders among offenders in criminal justice settings, identifi- cation of a single disorder (i.e., either mental health or substance use) should immediately trigger screening for the other type of disor- der. Somewhat longer periods of screening and assessment may be needed for offenders with cognitive deficits (e.g., limited attention span) related to their mental disorders.

Counselors may need to allow breaks during interview sessions, move at a slower pace during the interview, and obtain collateral information to verify key infor- mation related to mental disor- der symptoms, treatment and medication use, and interactive effects of co-occurring disorders.

Depending on the criminal jus- tice setting, screening may include a brief interview, use of self-report instruments, and review of archival records. A number of short self-report instruments are also available to examine the presence of mental disorder symptoms (Peters and

38

Advice to the Counselor: Screening Specific Populations

• It may be necessary for a counselor to modify screening and assessment instruments to be sensitive to cultural and other differences.

• Women respond differently to the screening process than men, and a longer, more flexible form is often use- ful to explore unanticipated areas that may arise.

• Many adaptations have already been developed and vali- dated. For instance, new versions of the ASI have been developed for use among American Indians and with women.

• Counselors interested in modifying instruments should consult the research literature to identify new adapta- tions or scales for existing instruments.

Chapter 2

Bartoi 1997). A mental status examination is also provided during many screenings for co- occurring disorders. In addition to examining key symptoms, mental health treatment histo- ry, and family history of mental disorder, it is helpful to assess the interactive effects of both disorders to determine whether there is an independent mental disorder, or if mental dis- order symptoms are present only when the offender uses drugs or alcohol.

Screening for suicidal thoughts and behavior should occur on an ongoing basis for all offenders with co-occurring disorders in the criminal justice system. This screening is par- ticularly important for offenders with severe depression or schizophrenia and individuals who are experiencing stimulant withdrawal. Suicide screening should be conducted at the time of transfer to new institutions, or at dif- ferent stages in the justice system (e.g., arrest, pretrial diversion, probation). All sui- cidal behavior should be taken seriously and assessed promptly to identify the types of ser- vices needed. For more information see TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c).

Integrated Screening and Assessment— Sample Approaches Programs often integrate a variety of screening and assessment instruments to place clients in the most appropriate treatment program. Several sample models of integrated screening and assessment implementations are described below.

Colorado Department of Corrections (CDOC) Colorado has a unique screening and assess- ment approach applied to offenders in both prison and community settings. All inmates transferred to CDOC for supervision receive a comprehensive screening and assessment for substance abuse problems, including the

Alcohol and Substance Use Screening and the Level of Service Inventory–Revised (LSI-R). Based on the instruments, an extensive treat- ment matching approach places offenders in correctional settings where intensity varies from no treatment to therapeutic communi- ties. The treatment matching approach defines key criteria for admission to each level of correctional treatment services based on the history of involvement in correctional treatment, individual motivation, social sup- port, living arrangements (if in noninstitu- tional settings), level of mental disorder and substance abuse symptoms, substance depen- dence symptoms, and other factors (O’Keefe 2000).

Florida Department of Corrections (FDOC) Florida has developed an integrated screening and assessment system for all inmates enter- ing its reception centers. The system uses the SSI-SA coupled with a records review (e.g., referrals from drug courts, history of DUI or drug offenses, FDOC treatment history) and a self-report gathered from interviews during the reception process. Responses from the various sources are weighted and then used to determine the offender’s needed intensity of treatment and placement. Those inmates placed in services are administered a further assessment on transfer to a permanent insti- tution, including the ASI and other psycho- social information. Key screening and assess- ment information is computerized and avail- able to treatment, classification, and proba- tion and parole staff (U.S. Department of Justice 1991).

Jacksonville, Florida, Adult Drug Court Programs This jurisdiction takes an integrated approach to screening and assessment that blends information from screening instru- ments, interviews, and archived records. For example, in the Jacksonville Adult Drug Court program, offenders are first inter-

39Screening and Assessment

viewed and offered treatment by their attor- neys and the public defender. After that, sev- eral steps are followed:

1. Treatment Accountability for Safer Communities (TASC) screens every offend- er in the program (either in jail or in the TASC office) for the likelihood of sub- stance abuse or dependency, using the agency’s screening form, coupled with a commercially available screen.

2. For offenders with substance use disor- ders, the need for treatment is evaluated using section 1 of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria, Second Edition, Revised (PPC-2R) (ASAM 2001).

3. For offenders who need treatment, place- ment criteria are assessed with the other sections of the ASAM PPC-2R, which include prior treatment history; biomedi- cal, emotional, and behavioral conditions and complications; treatment acceptance/ resistance; relapse and continued use potential, and recovery environment.

4. For offenders placed in treatment, a DSM- IV diagnosis is provided.

All screening and assessment information, the offender’s treatment progress, and program evaluation and monitoring data are stored in an MIS that is available to drug court staff, including the drug court judge who can access key information such as recent drug test results during drug court status hearings. The MIS was developed by the drug court staff, court technology staff, and the City of Jacksonville. A juvenile MIS is being devel- oped (Cooper 2002).

Orange County, California, Drug Court Program Orange County targets nonviolent offenders charged with possession or being under the influence of illicit drugs, first determining the offender’s eligibility and suitability for the Drug Court Program. To determine eligibility for the Drug Court Program, the district

attorney’s office flags offenders charged with possession or being under the influence. Then, probation staff reviews prior arrest history and interviews the offender about substance abuse history and willingness and ability to comply with program requirements. Finally, clinical staff from the program’s treatment providers complete a screening interview.

Eligible candidates are given a predetermined period of time in which to either plead guilty or opt into the treatment program. When candidates opt for treatment, suitability is then determined. This entails a full assess- ment, including a complete review of criminal history, the circumstances surrounding the charged offense, the results of any prior interactions with the criminal justice system, and a risk/needs assessment (with the National Institute of Corrections’ version of the LSI) to assess treatment needs and risk of reoffense. Finally, clinical staff conducts an ASI and a full psychosocial history to deter- mine the offender’s motivation for treatment, desire for change, emotional stability, and ability to comply with program requirements. The program runs for 18 months, with reassessments every 6 months to re-evaluate risk/needs scores (again using the LSI). The new scores are then used by the Drug Court Team (e.g., clinical staff, judge) to adjust supervision and treatment strategies.

Conclusions and Recommendations The consensus panel believes that the follow- ing are important points and recommenda- tions about screening and assessment for criminal justice populations:

• An effective screening and assessment approach will encourage appropriate refer- ral of offenders to different levels of treat- ment and will reduce the likelihood that offenders are released to the community without treatment (see chapter 3 for related discussion).

40 Chapter 2

41

• Appropriate assessment for substance abuse treatment in criminal justice settings exam- ines the substance abuse history, psychopa- thy and related risk factors, history of men- tal health problems, and other psychosocial areas that are affected by substance abuse.

• Intensive treatment should clearly be reserved for offenders who have at least moderate substance abuse problems and at least moderate risk for criminal recidivism. Intensive treatment for low-risk offenders will have only a minor impact on reincar- ceration rates. However, there is still con- siderable work to be done to determine the most effective procedures for treatment matching with offenders.

• Failure to identify incarcerated offenders who need postrelease treatment reduces the impact of positive change that occurred during correctional treatment.

• Improved instruments and procedures for substance abuse screening and assessment will assist in matching offenders to appro- priate postrelease treatment services.

• Matching has not been consistently demon- strated to be effective, and only limited alternative approaches are available.

• Because reports of offenders’ drug prob- lems are incomplete or contain contradicto- ry information, other collateral sources of information need to be obtained (e.g., drug test results, correctional records) that can be combined with self-report information to make referral decisions. For example, in many correctional facilities, drug tests are used to flag the need for treatment—even when an offender denies recent substance abuse. Similarly, criminal records may indi- cate substance abuse problems, based on a history of drug-related or DUI/DWI arrests, or presentence investigation results.

• While most staff may conduct screenings, staff with appropriate training should pro- vide assessments and related diagnoses and treatment plan recommendations.

• Screening and assessment instruments vary considerably in their ability to detect sub-

stance use disorders and to provide infor- mation regarding other areas related to substance abuse. A range of substance abuse screening and assessment instruments have been validated for use with offenders, and some are available at relatively little expense.

• The psychometric properties of screening and assessment instru- ments should be carefully reviewed, and choice of instruments based on demonstrated reliability and validity within substance abuse populations, and optimally, the utili- ty of instruments in criminal justice settings.

• A tiered screening and assessment approach could be developed in set- tings in which sev- eral types of treat- ment services are available. The ini- tial screening includes a broad filter to detect those who have substance abuse problems, while the more intensive assessment reviews specific treatment needs and risk levels so that the offender can be assigned to an appropriate level of treatment.

• Screening and assessment information should be obtained at each major point of transition within the criminal justice system (e.g., booking to jail, placement on proba- tion). In some cases, relevant information can be obtained from previous stages in the system, for example through transfer of records from probation to institutional set- tings.

Screening and Assessment

A range of

substance abuse

screening and

assessment instru-

ments have been

validated for use

with offenders,

and some are

available at

relatively little

expense.

• Offenders initially assessed with symptoms of co-occurring disorders should be evaluat- ed over an extended period of time to exam- ine whether these symptoms resolve in the absence of substance abuse. This reassess- ment should be conducted by staff members who understand patterns of symptom inter- action among co-occurring disorders.

• Screening and assessment for a prior histo- ry of physical and sexual abuse should be conducted routinely, particularly in settings that include large numbers of female offenders. Staff training is needed to devel- op effective interviewing approaches related

to the prior history of abuse, counseling approaches in dealing with abuse and trau- ma issues, and in making referral to mental health services.

• Memoranda of understanding and other formal agreements can be developed across different agencies working within the crimi- nal justice system to promote sharing of screening and assessment information. Key information related to treatment progress, outcomes, diagnoses, and ancillary services needs should be communicated across dif- ferent points in the criminal justice system.

Chapter 242

43

In This Chapter…

Treatment Levels and Components

Potential Barriers to Triage and Placement

Creating a Triage and Placement System

Compiling Information To Guide Triage and

Placement Decisions

Conclusions and Recommendations

Overview Identifying offenders in need of substance abuse treatment is only the first step in providing help to these individuals. Because no single treat- ment has been shown to be effective for all offenders, effective matching to individual needs such as vocational or employment skills, family counseling, and mental health services improves the likelihood that the client will successfully complete treatment. Matching to specific treat- ment interventions also is cost-effective and improves the quality of ser- vices within existing programs. For example, offenders appropriately matched to either a high-structure, behaviorally oriented program or a low-structure counseling program consistently have significantly less severe problems and lower rates of substance abuse than those not appropriately matched to treatment programs. Finally, with only a lim- ited number of available intensive treatment slots (e.g., residential ser- vices) in many criminal justice settings, offenders placed in these pro- grams who do not need or desire intensive treatment may be disruptive or drop out of treatment prematurely, preventing others from benefiting from them.

This chapter provides detailed information on how to best use the infor- mation obtained through screening and assessment in order to match the offender to appropriate treatment services. It begins by discussing three major treatment categories and outlines barriers to placement. A detailed discussion of triage and placement follows.

Treatment Levels and Components The consensus panel believes that treatment matching in the criminal justice system is most effective when there is a continuum of services— ranging from low to high intensity. This section provides a brief descrip- tion of treatment levels that may be available in criminal justice set- tings. The continuum of treatment levels includes three major treatment categories: pretreatment services, outpatient treatment, and inpatient treatment (including residential care). Several types of program services

3 Triage and Placement in Treatment Services

often are available within each treatment level. As the text box above indicates, research suggests that all major treatment levels are effective. Nonetheless, the consen- sus panel believes that clients should be matched not only on the intensity of services they need, but also on the particular compo- nents that are responsive to their individual needs.

Pretreatment Services Pretreatment services, which are not part of primary treatment, include primary preven- tion, early intervention, and detoxification. Primary prevention and early intervention are not typically used in criminal justice settings.

• Primary prevention. These are services for people who have not used substances. Most

primary prevention programs are in schools or the community.

• Early intervention. This includes psychoed- ucational programs for those who have used substances and are considered to be at high risk for substance-related problems or have a history of substance abuse. Other inter- ventions include screening and assessment to identify substance abuse problems. Brief interventions also are appropriate for offenders who use substances but who do not meet the diagnosis of having a substance use disorder. For example, ongoing evalua- tion can help determine if referral to a more intensive level of care is needed. In some instances, early intervention can be used as short-term treatment for individu- als with low-severity substance abuse prob- lems.

44 Chapter 3

Effectiveness of Treatment Levels—Results From the DATOS Study

Results from the federally funded Drug Abuse Treatment Outcome Studies (DATOS) (Hubbard et al. 1997; Simpson et al. 2002) indicate that all major treatment levels (including long-term residential, short-term inpatient, outpatient, and outpatient methadone) are effective in reducing substance abuse and criminal activity. For example, reductions in weekly cocaine use from pretreatment to 1 year posttreatment followup ranged from 46 percent among short-term residential clients to 20 percent among outpatient methadone clients. Reductions in criminal activity from pretreatment to 1 year posttreatment followup ranged from 25 percent among long-term residential clients to 8 percent among outpatient clients.

Key findings and implications from the DATOS studies include the following:

• All substance abuse treatment modalities are effective in reducing substance abuse and criminal activity.

• Residential treatment programs of at least 3 months’ duration are particularly cost-effective for use with criminal justice clients.

• Client readiness for and commitment to change and engagement and retention in treatment are important predictors of treatment outcomes. These factors, when routinely assessed by criminal justice programs, may be useful in targeting offenders who need more intensive services (e.g., intensive case management).

• Measures of client engagement and treatment progress are good predictors of dropout from treatment. When routinely assessed, these predictors can help identify clients who require specialized interventions (e.g., peer mentors, motivational enhancement therapies, individual counseling) to sustain their involve- ment in treatment.

• Involvement in posttreatment peer support activities is helpful in preventing relapse. Clients are more likely to engage in ongoing peer support groups if they begin these activities during treatment.

• Among clients with prior treatment experience, outcomes are more dependent on the quality of relation- ships with treatment counselors than are outcomes for first-time clients (Franey and Ashton 2002).

• Detoxification. Medically supervised detoxi- fication services are required for offenders whose alcohol or drug abuse has caused severe and life-threatening symptoms (e.g., acute intoxication, blackouts). Although detoxification typically is conducted prior to the onset of substance abuse treatment, it is important to provide a thorough assess- ment during detoxification and to provide orientation to the recovery and treatment process. For more information, see chapter 2 of this TIP and the forthcoming TIP Detoxification and Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] in development a).

Outpatient Treatment Also referred to as ambulatory care, outpatient treatment provides a broad range of services without overnight accommodation and includes nonintensive and intensive outpatient treat- ment, methadone treatment, and day treatment or partial hospitalization. Some of these ser- vices can be provided following inpatient or residential treatment, or as followup care after involvement in a residential program.

• Nonintensive outpatient treatment. This is substance abuse treatment that includes professional assessment and treatment involving less than 9 hours per week in reg- ularly scheduled sessions. Nonintensive out- patient treatment often addresses related psychiatric, emotional, and social issues, and offers a forum to explore issues such as the relationship between violence and men- tal disorders. Nonintensive outpatient treat- ment also can accommodate clients with job or family responsibilities, as treatment ser- vices may be offered on weekends or evenings.

• Intensive outpatient treatment. This is sub- stance abuse treatment with professional assessment and treatment from 9 to 20 hours per week in a structured program. These programs can be held on evenings or weekends. (For more information see the forthcoming TIPs Substance Abuse: Clinical Issues in Intensive Outpatient

Treatment [CSAT in development d] and Substance Abuse: Administrative Issues in Intensive Outpatient Treatment [CSAT in development c].)

• Methadone treatment. This is a medically supervised outpatient treatment that pro- vides counseling while maintaining the client on the drug methadone. This regimen is used primarily for heroin or other opioid addiction and provides a legitimate, closely monitored substitute for illicit drugs. The client must be able to document at least a 2- year history of addiction to qualify for a methadone treatment program. It is rarely used with those who are incarcerated. (For more information see TIP 43, Medication- Assisted Treatment for Opioid Addiction in Opioid Treatment Programs [CSAT 2005a]).

• Day treatment or partial hospitalization. This is substance abuse treatment with pro- fessional assessment and treatment of more than 20 hours per week in a structured pro- gram. This is the most intensive of the out- patient treatment options and can be used for treating clients who demonstrate the greatest degree of dysfunction but who do not require inpatient or residential treat- ment. Evening and weekend programming often is included.

Inpatient Treatment and Residential Care Inpatient treatment options include intensive medical, psychiatric, and psychosocial treat- ment provided on a 24-hour basis. The contin- uum of residential care includes psychosocial care at the most intensive end and group living with no professional supervision at the least intensive end. It is unlikely that the full range of services will be available in any one commu- nity.

• Intensive residential treatment. This long- term treatment can be directed by a sub- stance abuse treatment professional or could be medically directed. Intensive resi- dential treatment is appropriate for people

45Triage and Placement in Treatment Services

with multiple problems, especially those with co-occurring mental and substance use disorders (COD). Psychosocial rehabilita- tion is always a goal of treatment. The duration of treatment in this setting varies considerably, from 3 months to as long as 2 years.

• Therapeutic community (TC). The tradi- tional TC is a long-term (15 to 24 months) rehabilitative model that is often staffed by recovering professionals, treatment and mental health professionals, and vocational and educational counselors. Therapeutic

help from the resi- dential community paves the way for residents to recover from their sub- stance abuse prob- lems and to develop the vocational, edu- cational, and social skills they need to become productive members of society. Most TC residents have been involved with the criminal justice system. The theory and practice of the TC have been detailed in the liter-

ature (De Leon 2000), and the effectiveness of these programs has been documented both in prisons and in community-based settings (Melnick et al. 2001). A 2-day train- ing course offered by the Mid-America Addiction Technology Transfer Center in Kansas City, Missouri, is available. This course consists of lectures, small groups, and instructional materials on the TC model and how it works. For more informa- tion go to www.mattc.org/index.html.

• Psychosocial residential care. This long- term (6 to 24 months) psychosocial care model has elements similar to the therapeu- tic community model in that it relies heavily on peer pressure as well as formal treat-

ment to shape behavior. It is appropriate for people with substance abuse problems and concomitant disorders that do not require acute medical or psychiatric inter- vention. People compliant with psychiatric and other prescription medications are appropriate for this level of care. The focus of care is on psychosocial rehabilitation.

• Medically monitored intensive inpatient treatment. This level of care involves around-the-clock medical monitoring, assessment, and treatment in an inpatient setting, usually by a nurse or nurse practi- tioner. It is used for clients who have acute and severe substance use disorders and who may also have a coexisting medical or psy- chiatric disorder. Such treatment generally involves a short to intermediate length of stay (7 to 45 days) and may include non- medical or social model programs with vari- able lengths of stay.

• Medically managed intensive inpatient treatment. This level of care involves around-the-clock, medically directed evalu- ation and treatment in an acute-care inpa- tient setting, usually by a medical doctor. This level of care is appropriate for the treatment of medical and psychiatric prob- lems that may require biomedical treatment (such as life support) or secure services (such as locked units). Such treatment gen- erally involves a short to intermediate length of stay (7 to 45 days).

• Short-term nonhospital intensive residential treatment. This treatment is generally 21 to 45 days in length and is designed to teach the client how to live a substance-free life and to provide motivation for the mainte- nance of such a lifestyle. Follow-up care on an outpatient basis and continued partici- pation in peer support groups is recom- mended to maintain the recovery process begun in the residential setting.

• Halfway house. Residents are expected to follow house rules and share house respon- sibilities in a residential setting under staff supervision. Residents generally find their

46

Accurate

screening and

assessment are

necessary for

effective

placement.

Chapter 3

own way to outside activities (e.g., work, court, counseling, vocational training, and schooling). The house sometimes offers treatment services. Length of stay is limited or unlimited depending on the attainment of specific progress goals.

• Group home. This refers to a residential, transitional living situation without any spe- cific treatment plan and minimal staff supervision. It is sometimes known as a three-quarter-way house. Residents may work and receive education, training, or treatment in the community. House resi- dents generally decide on admission of new residents. House responsibilities are shared, and the house is governed and run by its residents. The length of stay is generally unlimited as long as abstinence from substances is maintained; the Oxford House model includes complete resident self-governance and self-sufficiency. The key to success in all such models is that the living situation is substance free, which sup- ports abstinence among residents.

Potential Barriers to Triage and Placement

Inadequate Screening and Assessment Accurate screening and assessment are neces- sary for effective placement. However, resources, adequate time to conduct compre- hensive assessments, and trained staff are not always available in criminal justice settings. As a result, substance abuse treatment in criminal justice settings often is based on sparse and inadequate information (Knight et al. 2002).

Competing Demands in Institutional Settings A challenge for substance abuse treatment programs in institutional settings is the com- peting demands on offenders’ time. For exam- ple, a prison’s need for labor to fulfill its con-

tracts and maintain itself can compete with an offender’s needs for treatment. Or, inmates could be assigned to institutional education programs. In addition, there are also compet- ing demands for treatment. Treatment service options often are limited and waiting lists exist for most services in community-based programs. The community-based system of care across the country largely is funded to provide services to a nonoffender population. In some cases, prioritization of community treatment services for offenders has placed a strain on the limited number of available treatment slots.

Information Flow Issues regarding the transfer of information across different settings in the criminal justice system present a major barrier to effective placement in offender treatment services. For example, this might include a need for a cen- tralized database that can be accessed by vari- ous providers as offenders move through the system.

Creating a Triage and Placement System The consensus panel believes that to ensure appropriate treatment for offenders who abuse substances, the offender’s needs and available resources must be balanced. Coordination of treatment matching within the criminal justice system can reduce the long-term costs of incarceration and other criminal justice functions only if adequate personnel and funding are available for case management. Ongoing planning and coordina- tion among criminal justice staff, substance abuse treatment staff, and policymakers and other stakeholders is important to establish an effective treatment matching system.

Based on the experiences of consensus panel members, the optimal approach would be to assemble a team consisting of correctional/ supervision and clinical staff to develop a triage and placement system and to assume

47Triage and Placement in Treatment Services

responsibility for compiling and processing treatment matching information. Once the triage and placement system has been devel- oped, the team can review cases referred to treatment, transfers, and placement in high intensity or specialized treatment programs (e.g., co-occurring disorders services).

This coordinated approach also can ensure that ongoing troubleshooting occurs to adjust eligibility criteria, to check admission and transfer procedures, and to monitor reentry to the community. Although triage and place- ment teams do not necessarily meet on a daily basis, they are regularly involved in reviewing offenders’ placement status and decisions to place or transfer offenders to different pro- gram settings. Scoring criteria for assigning offenders to different levels of treatment often are developed by clinical staff with significant involvement and review by criminal justice staff (e.g., classification officers). Use of scor- ing criteria and development of a triage and placement database are useful for document standardization and treatment provision across different groups of offenders.

Following are key triage and placement activi- ties that the consensus panel believes can be jointly undertaken by a team of correctional and clinical staff:

• Developing a treatment placement database of treatment resources available in the com- munity or correctional facility

• Defining key characteristics of existing treatment programs and the types of offenders and associated levels of treatment needs with whom the programs are most successful

• Documenting the referral process with appropriate timeframes and communication requirements for each system

• Outlining the information to be shared between agencies and developing proce- dures for transfer of key information with- out breaching confidentiality (for more

information on confidentiality, go to www.hipaa.samhsa.gov and see CSAT 2004)

• Describing offender treatment and supervi- sion/management responsibilities for each organization to avoid duplication of efforts, interagency conflict, and lapses in monitor- ing offenders

• Evaluating the effectiveness of treatment matching practices and placement criteria on an ongoing basis

• Determining offenders’ eligibility for and access to health, mental health, and social services in the community

Triage and Placement Strategies Triage and placement strategies for offender treatment programs depend on the range and type of services available, specific eligibility requirements attached to various programs, and the resources available to manage this process. In some criminal justice settings (e.g., jails) only limited types of services are available, such as 12-Step groups or a more intensive treatment program. In these set- tings, elaborate triage and referral systems are unnecessary, and placement decisions are often based on a brief substance abuse screening and a brief risk screening (e.g., for violence, acute mental health symptoms) to determine eligibility for the program. This often is accomplished by a single staff mem- ber and through a combination of self-admin- istered tests, brief interview, and records review.

In settings that feature a range of treatment services, triage and placement are usually lengthier, often involving multiple staff and compilation of multiple sources of informa- tion. These settings often use a scoring system or “algorithm” to determine which offenders should receive priority for available treat- ment slots. The consensus panel recommends that in general, the sophistication of a treat- ment matching system should reflect the

48 Chapter 3

• Range of different levels of treatment intensi- ty available

• Scope of information needed to determine eli- gibility for admission to the various levels of treatment

• Consequences for “mismatching” offenders to the different levels of treatment

Under most conditions, triage and placement decisions are guided by the need to reserve program slots for offenders with more severe substance abuse problems and who present at least moderate risk for criminal recidivism (see Figure 3-1, next page). Research indi- cates that treatment programs targeting offenders with moderate to high risk for recidivism produce the greatest posttreatment reductions in recidivism and are more cost- effective (Andrews et al. 1990; Bonta 1997; Gendreau 1996). However, research does not support placement of moderate- to high-risk offenders in minimally intensive treatment services (e.g., educational groups, 12-Step groups) unless additional, more intensive ser- vices are also provided. In summary, offend- ers with more severe addiction problems and more significant risks for criminal recidivism do not experience positive treatment out- comes unless they are placed in highly struc- tured and intensive treatment programs. Conversely, assigning low-severity offenders to these high-intensity programs often is inef- ficient and counterproductive for people who use drugs casually, who are then exposed to the corrosive effects of more seasoned offenders with pronounced criminal attitudes, beliefs, and lifestyles.

Compiling Information To Guide Triage and Placement Decisions Screening and assessment are discussed com- prehensively in chapter 2. This section outlines how to use information derived from screening and assessment to make triage and placement decisions.

As described in Figure 3-1, placement and triage strategies in criminal justice settings often use a tiered approach. In the first stage of this process (screening and assessment), attempts are made to identify major mental health problems or psychopathy that would interfere with involvement in substance abuse treatment. If one of these problems is identi- fied, the offender can be directly routed to a specialized treatment or management unit/ program. This tiered approach enables crimi- nal justice staff to quickly identify offenders who are not good candidates for substance abuse treatment and prevents unnecessary substance abuse screening and assessment for offenders who would perform poorly in exist- ing substance abuse programs.

If a range of offender treatment options is available, placement in services usually is determined by the following factors:

• Risk for criminal recidivism

49Triage and Placement in Treatment Services

Advice to the Counselor: Triage and Placement

• Measurements of client readiness for change, commit- ment to change, and engagement in treatment are important predictors of treatment outcomes.

• In settings with limited services available, elaborate triage systems are unnecessary and placement often can be determined with a brief interview of the offender, some self-administered tests, and a records review.

• Accurate screening and assessment are necessary for effective triage and placement in the face of competing demands for resources.

• Level of offender needs for substance abuse, mental health and other psychosocial or med- ical services, and employment

• Offender motivation and readiness for treat- ment

• Other offender characteristics including cog- nitive and intellectual abilities, abilities to read and write, and related abilities to com-

municate in individual and group settings and to withstand stress in highly intensive therapeutic communities

Research indicates that treatment programs that place individuals in services according to these areas are likely to enhance outcomes for offenders (Andrews et al. 1990; Gendreau 1996). The following sections discuss each of

50

Figure 3-1 Placement and Triage Strategies

Source: Zimmerman 2000.

Chapter 3

these areas in relation to triage and place- ment services, identify information sources necessary for placement, and list instruments that can be used to compile the information. For more information on the instruments list- ed, see chapter 2 and appendix C.

Risk for Criminal Recidivism Assessment of the risk for future criminal and/or violent behavior is of vital importance in the process of assigning offenders to treat- ment programs within the criminal justice system. Offender characteristics and environ- mental factors used to estimate the likelihood of future criminal behavior are termed “risk factors.” (See chapter 2 for information on identifying risk factors.)

Once criminal risk factors are identified, research indicates that structured and inten- sive cognitive–behavioral approaches can address offenders’ “criminogenic needs” related to their dynamic risk factors (those that are likely to change over time) (Andrews and Bonta 1998; Wanberg and Milkman 1998). Andrews and Bonta (1998) have identi- fied several promising targets for treatment intervention based on dynamic risk factors:

• Developing and improving life management, problemsolving, and self-control skills

• Developing associations or relationships and bonding with prosocial and anticriminal peers and with prosocial and anticriminal role models

• Enhancing closer family feelings and com- munication

• Improving positive family structures to pro- mote monitoring

• Managing and changing antisocial thoughts, attitudes, and feelings

In general, offenders who are at high risk for criminal recidivism require more structured and intensive treatment interventions such as intensive outpatient treatment, day treat- ment, residential treatment, or TCs, while low-risk offenders are better suited for low-

intensity interventions such as outpatient treatment, drug education, and peer support or 12-Step programs (see Figure 3-1) (Falkin et al. 1999).

Information needed for triage and placement • Criminal history, including age at first

arrest, number and type of prior arrests, history of violence and aggressive behavior, history of incarceration, probation and/or parole revocations

• Age, education, marital status, employment history

• Characteristics of psychopathy, including entitlement, impulsivity, superficial inter- personal relationships, lack of empathy, sensation seeking, poorly controlled anger

• Nature of offender’s family and social net- work (prosocial versus procriminal)

• Other personality disorders, including paranoia

Instruments used to compile this information Use of some of these instruments is described in chapter 2.

• Psychopathy Checklist—Revised (PCL-R) and the Psychopathy Checklist–Screening Version (PCL-SV)

•Psychopathic Personality Inventory (PPI)

•Level of Services Inventory—Revised (LSI-R)

•Millon Clinical Multiaxial Inventory—III (MCMI-III), Correctional Form

•Personality Assessment Instrument (PAI)

•Novaco Anger Inventory

•Jesness Inventory

•Paulus Deception Scale

•Inventory of Sensation Seeking

51Triage and Placement in Treatment Services

Level of Substance Abuse Problems Offenders with current alcohol or drug dependence and a history of chronic sub- stance use generally require more structured and intensive levels of treatment (Knight et al. 1999b; Simpson et al. 1999a). There is some evidence that highly structured treat- ment approaches that use a cognitive–behav- ioral orientation are more effective for offenders with pronounced substance abuse problems, in comparison to less structured client-centered approaches that use nondirec- tive, supportive counseling strategies (Thornton et al. 1998). Offenders who have less serious substance abuse problems are likely to benefit from a variety of treatment options across a range of modalities and levels of intensity (Knight et al. 1999b; Simpson et al. 1999b).

Information needed for triage and placement • Substance dependence symptoms

• Substance abuse-related arrests (e.g., driving under the influence [DUI]/driving while intoxicated [DWI], drug possession and sales)

• History of substance abuse (frequency, quan- tity, type of substances, route of administra- tion)

• Drug test results or other pre- or postsen- tence information related to substance abuse

• History of involvement in substance abuse treatment services

Instruments used to compile this information Use of these instruments is described in chapter 2.

• Addiction Severity Index (ASI)

• Simple Screening Instrument for Substance Abuse (SSI-SA)

•Texas Christian University Drug Screen (TCUDS)

•Alcohol Dependency Scale (ADS)

Level of Mental Health Problems Offenders with co-occurring mental disorders have participated successfully in many sub- stance abuse treatment programs in criminal justice settings, although they generally have more pronounced difficulties in employment, family relationships, and physical health (Peters et al. 1992) and sometimes have cogni- tive deficits related to their mental disorders. Although offenders with co-occurring sub- stance use and mental disorders present unique challenges, their ability to participate in treatment programs varies according to their functioning level in several key areas, including the ability to sustain attention and to participate in individual and group inter- actions, their vulnerability to emotional con- flict, and the presence of acute symptoms (e.g., paranoia, delusions). As a result, triage should include a mental health assessment to examine the potential effects of mental health problems on their participation in available treatment programs. Even moderate to high levels of mental disorders can be accommo- dated in many criminal justice treatment pro- grams, particularly those with mental health and other health services staff available, and that feature specialized treatment services for people with co-occurring disorders (Edens et al. 1997).

Information needed for triage and placement • Acute mental disorder symptoms that can

influence the offender’s ability to partici- pate in individual or group treatment set- tings

• Suicidal or other violent behaviors

• Cognitive and interpersonal or social impairment caused by current mental disor- der symptoms, specifically related to atten-

52 Chapter 3

tion and concentration, problemsolving skills, interpersonal skills, and frustration tolerance

• Effects of stress and other environmental influences on mental disorder symptoms and related behavioral problems

• Likelihood of recurrence of mental disorder symptoms and behavioral problems given environmental conditions in available treat- ment programs

• Accommodations available in existing treat- ment programs to address mental disorder symptoms and behavioral problems

Instruments used to compile this information Use of these instruments is described in chap- ter 2.

• Minnesota Multiphasic Personality Inventory (MMPI)

• Millon Clinical Multiaxial Inventory—III (MCMI-III)

• Symptom Checklist 90-Revised (SCL90-R)

• Brief Symptom Inventory (BSI)

Offender Motivation and Readiness for Change The offender’s motivation and readiness for treatment is another key factor in triage for placement in substance abuse treatment. Motivation and readiness for change are important predictors of treatment compli- ance, dropout, and outcome, and this infor- mation is vital (Ries and Ellingson 1990). Treatment is likely to be ineffective until indi- viduals accept the need for treatment of their substance abuse as well as other related problems.

An offender’s motivation to participate in treatment is influenced by justice system sanctions and incentives, including court orders to complete treatment, probation revo- cation, more intensive mandatory treatment,

“good time” credit for involvement in correc- tional treatment, and incarceration in jail or prison. Offenders also may be motivated by negative consequences outside the justice sys- tem, including threats to stable housing, employment, family, and marriage (Ziedonis and Fisher 1994).

However, the consensus panel cautions that assessments of motivation and readiness for change that occur outside clinical settings can misidentify signifi- cant numbers of offenders who could benefit from involvement in sub- stance abuse treat- ment. Many offend- ers who initially appear unmotivated can quickly become engaged in treat- ment through peers who are committed to recovery and who are actively involved in treatment. Involvement in group counseling and contact with program partici- pants and staff can stimulate motivation for change in the previ- ously unmotivated offender.

Motivation for treatment changes over time, and offenders often cycle through several pre- dictable stages of change during the treatment and recovery process. The stages of change model has been developed to describe recov- ery from various types of addictive disorders (Prochaska et al. 1992), and includes the fol- lowing stages:

• Precontemplation (unawareness of substance abuse problems)

• Contemplation (awareness of substance abuse problems)

53Triage and Placement in Treatment Services

The offender’s

motivation and

readiness for

treatment is a key

factor in triage for

placement in

substance abuse

treatment.

• Preparation (decision point)

• Action (active behavior change)

• Maintenance (ongoing preventive behaviors)

Offenders who are in the precontemplation stage of change have little awareness of sub- stance abuse (or other) problems and have few intentions of changing their behavior. Awareness of problems increases in later stages, as the individual begins to consider the goal of abstinence. However, due to the

chronic relapsing nature of substance use disorders, movement through stages of change is not a linear process, and offenders often return to earlier stages of change before achieving sustained absti- nence.

Assessments of offenders’ motiva- tion for treatment and their current stage of change are useful in matching to different types of treatment and to developing treat- ment plans. For example, matching offenders to treat- ment services that

are appropriate to the current stage of change is likely to enhance treatment compliance and outcomes. Conversely, for offenders who are in the early stages of change, placement in treatment that is too advanced and that does not address ambivalence regarding behavior change may lead to unsuccessful termination from treatment. For individuals in the later stages of change, placement in services that focus primarily on early recovery issues also may lead to unsuccessful termination from

treatment. Several considerations are provid- ed in chapter 5 regarding matching treatment services to the offender’s stage of recovery. For more information, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b).

Information needed for triage and placement • Perceived severity of drug and alcohol

problems

• Interest in making changes in drug and alcohol use

• Steps that have been taken by the offender toward abstinence from alcohol or drugs

• Perceived importance of receiving sub- stance abuse treatment

Instruments used to compile this information • Circumstances, Motivation, Readiness, and

Suitability Scale (CMRS) (De Leon and Jainchill 1986; DeLeon et al. 1994)

• Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

• University of Rhode Island Change Assessment Scale (URICA) (DiClemente and Hughes 1990)

Examples of Triage and Placement Approaches The consensus panel thought that the following three examples demonstrated effective use of triage and placement strategies.

Florida Department of Corrections The Florida Department of Corrections has operationalized a multilevel triage process to refer inmates to substance abuse treatment programs. This process involves the following steps:

54

Matching

offenders to

treatment services

that are

appropriate to the

current stage of

change is likely to

enhance treatment

compliance and

outcomes.

Chapter 3

• Review by classification staff to examine sentence structure, prior arrests, and cor- rectional history.

• Brief screening for substance abuse prob- lems and dependence symptoms using a modified version of the SSI-SA.

• Personal interview.

• Determination of the need for treatment based on the substance abuse screening, the history of drug or alcohol offenses, prior history in correctional treatment, recom- mendations by drug courts or other sen- tencing courts, and staff or self-reported referral for treatment.

• Assignment of a “priority score” for sub- stance abuse treatment, based on the sub- stance abuse screening score, the number of prior substance abuse offenses, number of prior correctional treatment episodes, posi- tive drug test results, and counselor inter- view results.

• Routine identification of inmates prioritized for substance abuse treatment through “flags” initiated within the computerized database.

Several of the components contributing to the priority score are weighted, including recom- mendations for treatment from drug courts or other sentencing courts, DUI manslaughter convictions, and unsuccessful termination from community corrections residential treat- ment programs. The inmate priority score is entered on a computerized database. Inmates with high priority scores are then transferred to facilities with substance abuse treatment programs, where an additional substance abuse screening and interview is conducted. Priority placement in intensive treatment ser- vices is provided for inmates with at least 12 to 18 months remaining on their sentence.

Megargee and Case Management Classification Systems Correctional systems have long used a variety of typologies to match clients to treatment and supervision approaches in institutional and community settings. These typologies usually are based on a combination of crimi- nal history variables and psychosocial char- acteristics. One example of a multidimension- al treatment matching system is the Megargee System, which is based on an extensive analy- sis of Minnesota Multiphasic Personality Inventory (MMPI) responses given by a large sample of Federal prison inmates. Ten dis- tinctive profile types have been identified, each with varying treatment implications that range from recommended placement in the least restrictive setting to placement in spe- cialized mental health facilities (Vigdal and Stadler 1996).

The Case Management Classification (CMC) system was developed by the Wisconsin Department of Corrections. Based on an offender’s responses to a 45-minute semistructured interview, four categories are used to determine treatment assignment with- in the correctional system:

1. Selective intervention for offenders who have led relatively stable, prosocial lives. The current offense resulted from an isolat- ed stressful event and represents a tempo- rary lapse.

2. Environmental structure for offenders lack- ing social and vocational skills who are typi- cally led by others into criminal activity.

3. Casework control for offenders with very unstable lives who are actively involved with drugs or alcohol and have a number of prior arrests.

4. Limited setting for offenders with long-term criminal involvement and who are comfort- able with their criminal lifestyle and strive for success through criminal activity.

55Triage and Placement in Treatment Services

ASAM Patient Placement Criteria One approach that has been developed to assist in triage and placement decisions for substance abuse treatment services is the revised version of the American Society of Addiction Medicine (ASAM) Patient Placement Criteria (PPC-2R) for the Treatment of Substance-Related Disorders, Second Edition, Revised (ASAM 2001). These criteria provide guidance for substance abuse counselors and other treatment staff in deter- mining the best “match” between client char- acteristics and several levels of treatment ser- vices. An interview format of the ASAM PPC- 2R is under development for use in clinical settings. Within the ASAM approach, treat- ment matching is facilitated for several differ- ent levels of treatment, including the follow- ing:

• Level 0.5—Early intervention

• Level 1—Outpatient treatment

• Level 2—Intensive outpatient treatment/par- tial hospitalization

• Level 3—Residential/inpatient treatment

• Level 4—Medically managed intensive inpa- tient treatment

Client characteristics are described across six dimensions for each level of treatment. Within each of these dimensions, the client characteris- tics described are intended to reflect a good “match” between client needs and the treat- ment setting. Dimensions of client characteris- tics in the ASAM-PPC-2R system are

1. Alcohol intoxication and/or withdrawal potential

2. Biomedical conditions and complications

3. Emotional, behavioral, or cognitive condi- tions and complications

4. Readiness to change

5. Relapse, continued use, or continued prob- lem potential

6. Recovery environment

The ASAM approach, or similar dimensional matching strategies, may be useful for sub- stance abuse treatment staff within criminal justice settings. Although the ASAM criteria have not yet been formally adapted for offender populations, the PPC-2R could prove helpful in providing a structured vehi- cle for determining which offenders would benefit from different levels of treatment intensity, structure, and supervision. One additional dimension that could be useful to incorporate in criminal justice adaptations of the ASAM PPC-2R is the risk for criminal recidivism. Levels of treatment services speci- fied within the ASAM criteria would also need to be tailored to specific types of criminal jus- tice settings (e.g., drug courts, restitution or day treatment centers, in-jail and in-prison settings), with additional client–offender dimensional criteria developed for each of these new settings. Although this adaptation process would require some attention, there is likely to be significant overlap between client–offender dimensional criteria for these new settings (e.g., drug courts), and existing ASAM criteria for various settings (e.g., intensive outpatient treatment, therapeutic communities).

Conclusions and Recommendations The consensus panel recommends that several key points be considered when developing a triage and placement system for substance abuse treatment in the criminal justice system:

• An effective triage and placement system should be developed to ensure adequate training and availability of staff to conduct assessments.

• In general, offenders who have significant risk for substance abuse and criminal recidivism should be prioritized for initial placement in substance abuse treatment services, rather than in other institutional programs (e.g., educational or vocational/employment services). These offenders should be referred to intensive

56 Chapter 3

treatment programs (e.g., day treatment, intensive outpatient, residential services).

• Mental disorder symptoms and impairment should be carefully considered in determin- ing placement in substance abuse treatment services. The functional ability of inmates should be the central concern in triage and placement decisions, rather than mental disorder diagnoses.

• A centralized substance abuse treatment database should be created to organize results from screening and assessment, to help coordinate the triage and placement process, and to track offender progress in treatment.

• In addition to key information regarding substance abuse problems, risk for criminal recidivism, and mental health problems, triage and placement decisions also should consider the offender’s motivation and readiness for treatment, the length of sen- tence/incarceration, prior history in treat- ment, violence potential, and other related security and management issues.

• A centralized database that provides timely information on offenders as well as the availability of services should be developed to improve triage and placement.

57Triage and Placement in Treatment Services

59

4 Substance Abuse Treatment Planning

In This Chapter…

Assessing the Severity of Substance Use Disorders

Assessing the Severity of Co-Occurring Disorders

Criminality and Psychopathy

Client Motivation and Readiness for Change

Implementing an Effective Treatment Planning

Process

Conclusions and Recommendations

The good treatment plan is a comprehensive set of tools and strategies that address the client’s identifiable strengths as well as her or his prob- lems and deficits. It presents an approach for sequencing resources and activities, and identifies benchmarks of progress to guide evaluation.

—Center for Substance Abuse Treatment (CSAT) 1994d, p. 21

Overview While screening and assessment identify the offender’s need for sub- stance abuse and other treatment services, and triage and placement services match the offender to the proper treatment, the treatment plan is where the information gathered is used to put treatment into practice. A treatment plan is a map specifying where clients are in recovery from substance use and criminality, where they need to be, and how they can best use available resources (personal, program-based, or criminal jus- tice) to get there. At a minimum, the treatment plan serves as a basis of shared understanding between the client and treatment providers. Clients learn what is expected of them in program commitments and attendance.

There are many approaches to treatment planning, but they possess some basic commonalities; this chapter discusses each in further detail. The severity of substance abuse-related problems must be determined, since this is the basis for appropriate placement in a treatment pro- gram. In addition, the presence of co-occurring mental disorders must be assessed because these may limit the type of treatment approach and identify the need for psychiatric care. Also important is assessing fac- tors such as procriminal attitudes and psychopathy that may suggest persistent criminality unrelated to substance abuse. The degree to which the individual is motivated to change behavior and lifestyle is another critical factor that has a bearing on whether motivational enhancement interventions, sanctions, or more self-directed treatments are appropriate. Finally, offender-clients should be involved in develop- ing their treatment plan so that they can be referred to appropriate ser- vices in the community.

Assessing the Severity of Substance Use Disorders Treatment planning within the criminal jus- tice system requires a comprehensive assess- ment of an offender’s substance abuse history and patterns of use, including drug(s) of abuse, chronological patterns of use, specific reasons for use, consequences of use, and family history of drug and alcohol abuse. Often treatment involvement within the crimi- nal justice system is based primarily on a con- viction or plea to a drug-related offense. Although the number and type of substance- related charges is sometimes a fairly good indicator of substance abuse and related problems, the offense category alone is not a foolproof indicator of treatment need or of appropriateness of referral to a specific pro- gram. The presence of intoxicants in blood or urine at the time of arrest is a better, albeit imperfect, indicator.

Using multiple indicators for assessing the severity of a substance use disorder is impor- tant because individuals with few substance- related problems typically do not respond favorably to intensive treatment and fail to identify with the process of recovery. Close association with more severely affected offenders can result in the less-severe offend- er becoming socialized into a criminal and drug-oriented lifestyle through contagion of attitudes and introduction to a criminal social network. Minimally, an assessment of severity should focus on determining the impact of use on the individual’s community adjustment. Usually this also entails taking a drug history that inquires about the frequency, dosage, and types of drugs used. A drug history may also inquire about the times at which, or set- tings in which, an offender uses.

Assessment of the severity of a substance use disorder may lead to an actual diagnosis of a substance use or dependence disorder. However, most offender treatment programs consider routine use of illicit drugs without a diagnosable disorder to be a legitimate focus

for treatment, since any use is illegal and may result in arrest or violations of community supervision guidelines. Also, most settings lack the qualified staff and time required to make formal diagnoses, and clients are some- times in the setting for too short a time to delay treatment while awaiting formal diagno- sis of a substance use disorder. In these set- tings, clinical impressions are more feasible than are formal diagnoses, and common sense, assisted where possible by standard- ized assessment instruments, should prevail in deciding whether and how to provide treat- ment services. Fortunately, several standard- ized instruments with good psychometric properties are available in the public domain, or at low cost, for the purpose of screening and assessment of substance use severity (see chapter 2).

Assessing the Severity of Co-Occurring Disorders Another important area to assess in develop- ing a treatment plan is the presence and impact of psychological and emotional prob- lems, particularly those that are not the direct result of substance abuse. Offenders with severe substance use disorders have rela- tively high rates of affective disorders, anxi- ety disorders, and personality disorders. These disorders can contribute to the devel- opment of substance use problems, or the emotional disorders may develop as a conse- quence of the physiological effects of long- standing drug use and the stressful or trau- matic life events that are often experienced as part of a lifestyle in which drug use plays a central role. Some individuals have mental health problems prior to intake; others devel- op them during adjudication, incarceration, or community supervision. Commonly encountered disorders include anxiety, depression, and posttraumatic stress disorder (PTSD) (Teplin et al. 1996). Developing pro- grams to assist those with co-occurring mental and substance use disorders requires inte- grating treatments and modifying commonly

60 Chapter 4

used interventions to take into account possi- ble cognitive disabilities and increased need for support among these individuals. In addi- tion, system-level barriers in funding, staffing, and training must be overcome (Drake et al. 2001). (See also TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders [CSAT 2005c].)

Although the treatment of co-occurring severe mental disorders and substance use disorders sometimes is provided in specialized, more intensive programs, less severe mental disor- ders that do not cause major functional impairment can be treated and managed effectively within mainstream programs. Moreover, not addressing these underlying problems can increase the likelihood of relapse. It is important to note, however, that the early stages of recovery often are marked by increases in depression and anxiety, due, in part, to residual effects of substance with- drawal and also to the individual’s recogni- tion of consequences related to his substance abuse, including incarceration or other restrictions to his liberty. Likewise, substance abuse may mask an underlying mental disor- der that may not become apparent until the offender is no longer using drugs or alcohol. Thus, assessments should be repeated regu- larly during the treatment process.

Posttraumatic Stress Disorder and Depression Problematic early life experiences, physical and sexual abuse, witnessing violence among family and friends, and other traumatic life events often emerge as key issues in substance abuse treatment. Whether identified initially or after a period of treatment, it is important that these issues be reflected in the treatment plan, matched with interventions likely to be effective, and tracked with regard to progress. For example, while most clients will find that negative mood will decrease over the first few months of abstinence and treatment, an individual’s depression, nightmares, and other trauma-related symptoms might persist after several months. If symptoms do not require transfer to a mental health services program, this individual should be referred to mental health professionals for further assessment and treatment. The referral could result in recommendations for antidepres- sants and/or antianxiety medications and/or involvement in cognitive–behavioral therapy related to trauma and substance abuse issues. These interventions may be instrumental in preventing substance abuse relapse and allowing the client to continue making progress within her substance abuse treat- ment program.

Serious Mental Disorders Although they occur less frequently than PTSD and mild anxiety or depression, serious mental disorders (including schizophrenia, delusional disorder, bipolar disorder, and major depression) can adversely affect the ability of treatment programs to man- age an offender’s behavior. Behav- ioral disorders that involve self-harm (e.g., cutting or burning oneself, suici- dal threats or attempts), and impul- sive and uncontrollable aggression are particularly problematic to manage in a treatment setting. These more severe

61Substance Abuse Treatment Planning

Advice to the Counselor: Mental Health Issues

• After a few months of abstinence, most clients will show a decrease in negative mood related to their substance use. However, abstinence may reveal the presence of other, more serious mental disorders (such as posttrau- matic stress disorder, depression, schizophrenia, intermit- tent explosive disorder, or borderline personality disor- der) that will require collaboration with a mental health professional. Some individuals will achieve a level of adjustment that will allow them to continue in main- stream substance abuse treatment, but others will require more intensive intervention for their co-occur- ring disorders.

behaviors require involvement of mental health professionals for diagnostic workup and treatment interventions.

In the case of serious mental disorders and threatening behavioral disorders, an assertive, psychiatrically based treatment approach is needed during the most intensive phases of the disorder. After the more severe symptoms have abated (usually through medi- cation and behavioral management on a spe- cialized unit or in a hospital), collaboration between mental health and substance abuse professionals is needed to determine the best approach to manage and treat the individual. Some individuals will achieve a level of adjustment that will allow mainstreaming within substance abuse programs, with medi- cation monitoring in collaboration with medi- cal staff. Other individuals will require more intensively integrated care and intervention for their co-occurring disorders.

Intermittent Explosive Disorder Treatment planning for individuals who pre- sent with an intermittent threatening behav- ioral disorder is complex. If these behaviors are fairly frequent, it will be impractical to manage the individual in a mainstream pro- gram. If these behaviors occur infrequently, the individual may be manageable in the mainstream setting, but only with additional assessment as to the causal antecedents (immediate situation and circumstances) of the outbursts or self-harm behaviors and an analysis of the incentives and perpetuating factors that fuel the behavior. With this assessment in hand, the treatment plan can be used to alert and guide the individual and staff regarding triggers for the unwanted behaviors and ways to defuse their appear- ance, or ways to limit the threat they present to the client and others.

The treatment plan in such cases will often involve the client’s committing to a behavior contract that requires reporting strong temp- tations or urges to the staff, specifies self-con-

trol strategies, and clarifies the consequences of the behavior, which may include sanctions for misconduct, intensification of treatment, or removal from the mainstream program with referral to a specialized behavioral unit. In many cases psychiatric consultations and medication management can be helpful.

Borderline Personality Disorder Individuals diagnosed with borderline per- sonality disorder (BPD) sometimes engage in severely disruptive behaviors. Individuals with this disorder typically experience many specific negative emotions (vulnerability, hos- tility, sadness, anxiety, etc.) or a nonspecific but intense sense of distress or “feeling bad.” This is combined with an inability to monitor and control emotions, alternating chaotic or contradictory ways of relating to self and oth- ers, and self-harm or dramatically self- destructive behaviors.

Dialectical Behavior Therapy (DBT) (Linehan 1993) has been developed specifically for treatment of BPD. This treatment requires specialized training, and manualized inter- ventions are available to guide group treat- ment sessions. DBT approaches can be suc- cessfully integrated with substance abuse treatment in much the same way that the treatment of severe mental disorders is coor- dinated with mainstream substance abuse treatment. Clients participating in DBT do so on a voluntary basis, and agree to attend skills training sessions and to work on reduc- ing suicidal or self-injurious behavior and other behaviors that interfere with treatment. Core DBT interventions involve careful exam- ination of clients’ problems and emotional difficulties, as well as a recognition that these problems make sense within the context of current life situations. Problemsolving skills are used throughout DBT, as are contingency management, cognitive–behavioral treatment approaches, supervised “exposure” to past trauma events, and use of psychotropic medi- cation.

62 Chapter 4

The DBT approach typically consists of at least 1 year of treatment, comprising weekly individual psychotherapy and group therapy sessions. Individual sessions explore problem- atic behaviors and chains of events leading up to the behaviors, while therapy sessions focus on interpersonal effectiveness skills, tolerance of distress, emotional regulation, and self- awareness or “mindfulness” skills. The pre- treatment phase of DBT is dedicated to assessment, orientation, and developing com- mitment to the treatment process.

Three subsequent stages of treatment empha- size self-examination and development of skills. Stage 1 of DBT involves examination of suicidal and other problem behaviors that interfere with treatment and the client’s qual- ity of life, and development of related skills to address these issues. Stage 2 of DBT address- es problems related to PTSD, and Stage 3 is focused on developing self-esteem and addressing individual treatment goals.

Criminality and Psychopathy In developing treatment plans for substance- involved offenders, it is important to assess whether criminal attitudes and behaviors pre- dated drug and alcohol abuse and whether criminogenic personality features will impede involvement in treatment. This assessment is useful in constructing a balance between risk containment and rehabilitative activities pre- scribed for the offender, and, along with sub- stance use disorder severity and presence of

psychopathology, is one of the most important predictors of treatment outcome. Although substance abuse treatment has become increasingly integral to the criminal justice system, it should not be assumed that crimes committed by drug-involved offenders are solely the result of drug-acquiring behavior or are attributable to intoxication and impaired brain functioning. The majority of drug-involved offenders show a dramatically reduced pattern of criminal activity while they are abstinent and involved in treatment, as compared with periods of active substance abuse (De Leon et al. 1982; Deschenes et al. 1991). Nonetheless, some offenders persist in committing a high frequency of property and violent crimes, even in the absence of sub- stance abuse.

Sources of Criminality Many offenders begin their criminal careers before the onset of substance use, with drugs

and alcohol being more symptomatic of a broader pattern of delinquency, act- ing-out, and social deviance. Three sources of criminal behavior that are closely associated with drug use can be identified: procriminal values, pro- criminal associates, and psychopathy.

Procriminal values Procriminal values in adults are most often the result of the combination of

early involvement with delinquent peers, the experience of parental neglect or abuse, the absence of prosocial resources and strengths (such as literacy, employability, and social skills), and exposure to an overly permissive or procriminal environment, such as an unsafe school or crime-ridden neighborhood. Examples of procriminal values include intol- erance for personal distress and unwillingness to accept responsibility for behaviors that adversely affect others. Procriminal values and attitudes, coupled with a longstanding pattern of antisocial and criminal behaviors, are the key elements of psychopathy.

63Substance Abuse Treatment Planning

Advice to the Counselor: Borderline Personality Disorder

• Severely disruptive clients may have borderline personali- ty disorder. Dialectical Behavior Therapy has been devel- oped specifically for treatment of this disorder and can be successfully integrated with substance abuse treat- ment programs.

Procriminal associates Procriminal associates can develop from life in proximity to high-frequency crime areas, but more often the choice of criminal associ- ates is the logical result of “criminal thinking” and procriminal values. Procriminal associa- tions are also formed during incarceration or involvement in criminal justice programming. Often these are not balanced by prosocial friendships because of the person’s inability to overcome the stigma of having a criminal record or attract and maintain relationships with individuals who are socially less “marginal.”

Procriminal values and thinking, as well as criminal associates, are rooted in normal cog- nitive, emotional, and social processes, such as the need for belonging and approval, the need to feel that one has gotten a “fair deal” in life, and the need to feel a sense of self-effi- cacy and security. Because the origin and perpetuation of these factors are based pri- marily in normal psychosocial aspects of the person—that is, they are based on thoughts, emotions, and ways of relating that are within normal limits—they are fairly susceptible to being modified using the psychosocial meth- ods common to the major substance abuse treatment modalities. Individuals whose crim- inality results primarily from these two fac- tors can learn new ways of thinking and valu- ing, as well as new ways of feeling and how to manage their feelings, especially in the con- text of developing new prosocial and pro- recovery relationships. Treatment approaches that address criminal thinking are discussed in chapter 5.

Psychopathy Psychopathy is distinguished from both pro- criminal values and procriminal associates in that it is most often conceptualized as a per- sonality trait with primarily biological under- pinnings. When this trait becomes extreme it can be described as a personality disorder. Personality disorders are distinctive, long- standing, pervasive patterns of behavior,

which usually begin early in life. Personality disorders tend to affect almost every aspect of a person, such as thinking, feeling, perceiv- ing, and relating to others, with worsening cycles of self-defeating and maladaptive behavior. Most theorists and researchers view psychopathy as the result of interactions between biological differences—primarily located in the brain (Anderson et al. 1999; Laakso et al. 2001)—and the most early and basic experiences that shape the personality, such as the experience of bonding, attach- ment, and concern for others (Hare 1996). Psychopathy is expressed in ways of thinking (impulsive, irresponsible, and grandiose) and feeling (without empathy and shallow) that typically result in behaviors that seriously infringe on the rights of others.

In contrast to the BPD, the most notable characteristic of individuals with severe psy- chopathy (other than persistent criminality and exploitation of others) is the lack of nor- mal attachment to and value for other people. Although they can be glib and charming, peo- ple with psychopathy have a shallow and fleeting ability to experience, express, and understand social emotions such as embar- rassment, self-consciousness, shame, guilt, pity, and remorse. This affective-interperson- al deficit often is expressed in the form of cold and callous use of other people without regard for their feelings or well-being. This lack of empathy is usually the basis for a lack of remorse for criminal behavior and is sup- ported by the belief that society and the vic- tim are at fault, rather than the perpetrator, or that the damage done by one’s crimes is of little consequence (Hare 1998a).

The Psychopathy Checklist–Screening Version (PCL–SV) can provide an important screening mechanism for identifying those offenders who may require a more extensive evaluation. The PCL-SV and other instru- ments for examining psychopathy are dis- cussed in more detail in chapter 2. All other things being equal, individuals who are low in psychopathy can be expected to respond favorably to substance abuse treatment in the

64 Chapter 4

criminal justice system and to significantly reduce their criminal behavior as the result of this treatment. Individuals who are in the moderate range of psychopathy will benefit from treatment but will require more inten- sive monitoring, an emphasis on consequences and potential sanctions versus personal aspi- rations and goals, and vigilance for deception and manipulation of treatment and criminal justice supervisors.

Individuals high in psychopathy require the most intensive in-prison and community supervision and monitoring. Intensive treat- ments that engage the client in deep emotional processing, that require “working through” life experiences to develop insight, or that stress the development of social skills for their own sake should be avoided for this group. Treatments should be limited to prac- tical relapse prevention activities, including relapse to illegal or seriously self-defeating forms of manipulation and exploitation of others, with increased monitoring for drug use. All self-reported aspects of community adjustment must be carefully corroborated by first-hand observation or reported by an independent third party, including, for exam- ple, attendance at required programming, status of living conditions, type and hours of work, criminal background of close associ- ates, and use of leisure time.

Offenders with severe psychopathy tend to do poorly in treatments of all types, when com- pared to those without severe psychopathy. Of great importance is the sur- prising and paradoxical finding (now replicated) that offenders with severe psychopathy who are given intensive treatment re-offend more frequently and more seriously than offenders with psychopathy who go untreated (Hobson et al. 2000; Reiss et al. 1999, 2000). In other words, treatment may be contraindicated for offenders with severe psychopathy.

Client Motivation and Readiness for Change The successful implementation of a treatment plan depends, to a great extent, on the client’s motivation and readiness for change. Motivation level has been found to be an important predictor of treatment compliance, dropout, and outcome, and is useful in mak- ing referrals to treatment services and in determining prognosis (Ries and Ellingson 1990). Motivation is sometimes thought of as an emotional commitment to voluntary engagement in treatment. However, this view is overly simplistic, since motivation can be influenced by many factors including the threat of sanctions or the promise of rewards for treatment engagement (such as reduced jail time, access to needed services, or trans- fer to a desired correctional facility where the treatment will take place). Motivation and readiness for treatment are expected to change over time, and individuals often cycle through several predictable “stages of change” during the treatment and recovery process. Due to the chronic relapsing nature of substance abuse problems, offenders fre- quently return to previous stages of change before achieving recovery goals and sustained periods of abstinence. (See chapter 3 for a discussion of the stages.)

A number of attempts have been made to link the readiness to change approach to a substance abuse-specific model that involves

65Substance Abuse Treatment Planning

Advice to the Counselor: Psychopathy

• Individuals high in psychopathy require the most inten- sive in-prison and community supervision and monitor- ing. Treatment should be limited to practical relapse pre- vention activities, including relapse to illegal or seriously self-defeating forms of manipulation and exploitation of others, with increased monitoring for drug use.

• All self-reported aspects of community adjustment must be carefully corroborated by first-hand observation or an independent third party.

“phases” of recovery. Each phase of recovery is typified by a characteristic level of motiva- tion, often reflected in engagement with treat- ment and with specific recovery-related activ- ities. These models have considerable value for both treatment planning and research as ways of describing and communicating about where a client is in regard to readiness (McHugo et al. 1995).

Assessment of treatment readiness and stage of change is useful in treatment planning and in matching the offender to different types of treatment. For example, matching offenders to treatment that is appropriate to their cur- rent stage of change is likely to enhance treat- ment compliance and outcomes. For individu- als in the early stages of change, placement in treatment that is too advanced and that does not address ambivalence regarding behavior change may lead to early termination from the program. For offenders who are in later stages of change, placement in services that focus primarily on early recovery issues may also lead to premature termination from treatment. Staff involved in treatment plan- ning should be careful to assess the offender’s stage of change and readiness for substance abuse treatment and to consider this informa- tion when developing treatment plan goals. Ongoing review of readiness for treatment can be provided through use of self-report instru- ments, focused discussion with the client, observation of the client within a treatment program, and review of collateral reports

from treatment staff, criminal justice staff, and family members. Several techniques for screening and assessment of readiness for change are discussed in chapter 3.

Motivation for change is so often an issue for criminal justice clients that perhaps most treatment plans should contain a section addressing motivation and readiness for change. Surprisingly, individuals who verbal- ize the greatest desire for treatment may not have more than a vague sense of their own motivation to escape the negative conse- quences they are currently experiencing, such as incarceration, debt, or ill health. However, staying focused on the positive consequences and rewards of recovery is an essential aspect of the recovery process. From the first point of intake to the final community supervision session, promoting and utilizing motivation should be an upfront aspect of criminal jus- tice management of substance abuse treat- ment. Motivational interviewing methods, providing feedback to clients on key aspects of assessment findings and progress toward treatment plan goals and intimate involve- ment of the client in the construction and revision of the treatment plan are important ways of enhancing client engagement in treat- ment. (For more information, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999b].)

Focus on Personal Strengths The strengths-based approach to treatment planning in juvenile justice and adult criminal justice settings has been received with enthusiasm in many quarters. This contrasts with the tradi- tional deficit-based approach to treatment planning for adults involved in the criminal justice system. Strengths can be recog- nized and used in treatment planning without neglecting deficits or decreasing the neces- sary emphasis on accountability and responsibility. Offenders

66 Chapter 4

Advice to the Counselor: Motivation for Change

• Treatment plans should contain a section addressing motivation for change. Clients may have only a vague sense of their own motivation for treatment. However, staying focused on the positive consequences of recovery is an essential aspect of the recovery process.

• From the first point of intake to the final community supervision session, promoting and utilizing motivation should be an upfront aspect of substance abuse treatment.

tend to exaggerate or minimize their strengths. Assisting clients in identifying and getting an accurate estimate of their personal strengths should emphasize, but not be limit- ed to, those that are relevant to recovery.

Strengths assessment often begins by deter- mining what interests or inspires the client or by identifying those things in which the client has a sense of pride. Therapeutic community settings often identify specific roles within the treatment environment that clients can take on as their strengths and work to develop them further. Other modes of intervention perhaps need to create roles or activities for clients that use their strengths or identify opportunities outside of the program itself. Women’s programs often emphasize the strengths that enabled survival during peri- ods of abuse or neglect. Identifying and work- ing with strengths in the treatment planning process allows the client to be less defensive about the identified deficits and problem areas in the same plan. It is important, how- ever, that the perception of the strengths as legitimate and of value be shared among the members of the planning team and with the client.

Implementing an Effective Treatment Planning Process

Offender Involvement in the Development of the Treatment Plan The consensus panel believes that it is essen- tial for clients to be involved in setting case management goals that are in their own best interests. Success of the treatment plan can be greatly aided by the client’s involvement in the development of specific objectives and interventions. An example of this process is the Client’s Recovery Plan (CRP), in use at the Walden House program in San Francisco (see Figure 4-1, next page). The client docu-

ments his perception of his circumstances, needs, and tendencies, and these are incorpo- rated into the program treatment plan. The CRP opens the dialog between the client and the staff on a more equal footing.

Coordination of Treatment Planning and Sharing of Treatment Information Treatment planning activities in criminal jus- tice settings should include the full range of professionals involved in supervising, moni- toring, and providing therapeutic services. In noncustody settings, it is useful to have pro- bation or parole officers involved in this pro- cess, in addition to staff from halfway houses, employment/vocational services, and family members. In custody settings, treatment plan- ning could involve case management or tran- sition staff who may be responsible for coor- dinating prerelease plans and making arrangements for treatment appointments fol- lowing release from custody. The consensus panel recommends that treatment plans be updated at different transition points in the criminal justice system (e.g., following release from custody, transfer to less intensive super- vision status, or departure from a halfway house setting), as the offender’s motivation, response to environmental stressors, and level of involvement in treatment may significantly change. Signed releases of confidential infor- mation and interagency memorandums of agreement can help to ensure that treatment plans and other key information are trans- ferred to appropriate staff during these tran- sition points.

Relapse prevention plans often are used with- in community-based treatment programs in the criminal justice system to develop a coor- dinated approach to supervision, treatment, and judicial supervision that recognizes the importance of substance abuse relapse. Relapse prevention plans often describe high- risk situations for the offender which increase the likelihood of relapse, relapse “triggers” or cues (e.g., interpersonal conflict, negative or

67Substance Abuse Treatment Planning

68 Chapter 4

Figure 4-1 Client’s Recovery Plan (CRP)

Name ________________________________________ Date ____________________ WH # ______________________

Note to client This form is provided to you, as a Walden House client, in order to obtain yyoouurr input into your treatment plan. Your counselors will be evaluating you and your treatment needs based on the Psycho-Social History and Assessment that you provided them. This form is your opportunity to do your own self-evaluations on the same cat- egories.

Instructions Please describe your own preferences or ideas of what you feel you need in the following categories (if the category does not apply, please put “N/A”).

Drug and Alcohol ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Childhood/Family ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Relationship/Marital/Sexual ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Friendship/Recreation and Leisure/Religious/Spiritual ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Parenting/Child Protective Services (CPS) ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Criminal Justice ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Education ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Employment ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

positive emotions, drug paraphernalia, old drinking or drug associates), skills to be developed to address problems related to relapse, and specific strategies to deal with relapse urges, “triggers,” and high-risk situa- tions. Relapse prevention plans are used in a number of drug courts, and help develop con- sensus among court, supervision, and treat- ment staff about an offender’s current “risk” level for relapse and in organizing responses to critical incidents and problem behaviors.

Linkages With Community Treatment For criminal justice clients who will not remain long in a jail setting, linkages to the appropriate community services are an essen- tial part the treatment plan. The shorter the jail detention, the more important these links become, especially if a client needs a range of services, including educational, vocational, legal, medical, and mental health. For these links to work most effectively, the treatment plan must include all relevant information

about the client that may be needed by the community providers involved. This will allow all the different parties to agree on their own responsibilities to the client as well as the conditions for reporting back to the case manager as needed for the client’s welfare. In some cases an interagency audit, however informal, can be useful to identify gaps in the treatment plan and barriers to the client’s progress, as well as the strengths present in the client’s situation.

Successful links with community agencies require careful planning and considerable resources to develop. Treatment planning and case management as a whole will be easier for treatment professionals if these relationships already exist and can be called upon quickly. Case managers can cultivate these relation- ships by being involved whenever possible in activities of the agencies they work with, such as by attending committee or planning meet- ings, in helping staff members of these organi- zations to develop offender programs and policies, and by contributing to resource materials and manuals. (See TIP 30,

69Substance Abuse Treatment Planning

Housing ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Mental Health ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Overall, is there anything else you feel you need that is not covered in the above areas that is related to your sub-

stance abuse recovery? ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

In your opinion, how much treatment time do you feel you need? Be specific. ______________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________

Your signature: _______________________________________________________________________________

Thank you. Your input is appreciated and will be taken into consideration in the development of your treatment

plan. You are to bring this completed form with you to your clinical assessment meeting.

Continuity of Offender Treatment for Substance Use Disorders From Institution to Community [CSAT 1998b].)

Conclusions and Recommendations The consensus panel recommends that several key points be considered when developing a substance abuse treatment plan for clients in the criminal justice system:

• Sufficient resources are needed for compre- hensive assessment and treatment planning, including adequate staffing, clerical sup- port, and access to computers and manage- ment information systems.

• When sharing information is not feasible (e.g., routinely providing detailed informa- tion to a drug court judge regarding offend- er disclosures in treatment), consultation, training, and written agreements are need- ed to define the types of information that will be shared, with whom, and under what circumstances.

• Procedures should be developed to control the flow of relevant information to the vari- ous staff involved in an offender’s treat- ment and supervision. These procedures are required to protect the privacy and confidentiality rights of offenders. (For more information on confidentiality, consult www.hipaa.samhsa.gov and see CSAT 2004.)

• The offender should be involved in all major aspects of the treatment planning process.

• Procedures should be adopted for in-prison treatment programs regarding information sharing and flow of treatment records from one institution to another. Such procedures should control access to treatment providers and provide protection against rerelease of information related to self-dis- closures of previous unreported criminal behavior or the intent to commit future crimes and psychiatric and medical histo- ries, except when required by law. (For more information on confidentiality, consult www.hipaa.samhsa.gov and see CSAT 2004.)

• Treatment plans should assess the severity of the substance use disorder as well as any COD in order to place the offender in an appropriate treatment setting.

• Treatment plans should address motivation and readiness for change.

• Treatment plans should incorporate a strengths-based approach.

• Offenders possessing some degree of psy- chopathy may respond less well to tradi- tional substance abuse treatment but bene- fit from intensive in-prison and community supervision that emphasizes consequences and sanctions for relapses.

• Correctional therapeutic community (TC) programs should consider use of instru- ments to measure client progress in treat- ment, as defined by the TC’s goals for social and psychological change.

70 Chapter 4

71

5 Major Treatment Issues and Approaches

Overview While many similarities exist between substance abuse treatment for those in the criminal justice system and for those in the general popu- lation, people in the criminal justice system have added stressors, including but not limited to their precarious legal situation. Criminal justice clients also tend to have characteristics that affect treatment. These include criminal thinking and criminal values along with the more typical resistance and denial issues found in other substance abuse treatment populations.

Many offenders also have a long history of psychosocial problems that have contributed to their substance abuse: interpersonal difficulties with family members, difficulties in sustaining long-term relationships, emotional and psychological problems and disorders, difficulty man- aging anger and stress, lack of education and vocational skills, and problems finding and maintaining gainful employment (Belenko and Peugh 1998; Peters 1993). These chronic problems often are associat- ed with reduced self-esteem, anxiety, depression, and enhanced expec- tations about the initial use of substances. Unsuccessful attempts at abstinence also tend to reinforce a negative self-image and increase the likelihood that offenders will use substances when faced with con- flict or stress.

This chapter addresses strategies for modifying substance abuse treat- ment services for criminal justice clients. Some of these strategies are underlying program components, such as incentives for program par- ticipation and emphasis on personal accountability; others are more directly related to clinical issues, such as intervening with criminal thinking and teaching basic problemsolving skills.

While the suggestions offered here are applicable to many criminal justice clients, it is important to note that treatment approaches must take into account the unique situation of the offender and his stage in the recovery process. Treatment plans and assessments should be con- tinually revised to reflect changes in the client’s situation, such as

In This Chapter… Clinical Strategies

Program Components and Strategies

Conclusions and Recommendations

recent relapses, continued sobriety, and improvements in mental and psychological functioning. For more on issues affecting spe- cific subpopulations within the criminal jus- tice system, see chapter 6.

Clinical Strategies Substance abuse counselors working with criminal justice clients are likely to face a host of challenges. Offenders may require help meeting basic life needs, such as finding housing, applying for a job, or cooking a meal. Moreover, counselors generally will have to motivate clients to find new ways to manage their feelings, control impulses, and work toward concrete goals. Confronting manipulation and setting boundaries are con- stant challenges for many substance abuse counselors who work with criminal justice clients.

This section discusses some of the issues that the counselor is likely to face, along with strategies for meeting those challenges. The second part of this chapter, “Program Components and Strategies” addresses a broader range of strategies.

Addressing Basic Needs It is difficult to label any particular needs of offenders who abuse substances as more basic than others. Offender needs vary depending on issues such as their legal status, gender, culture, sexual orientation, age, and function- al capacities. There are also significant differ- ences in what an individual experiences in different criminal justice settings (i.e., jail, prison, community supervision). Despite these differences, there are commonalities in the treatment needs of offenders. In addition to substance abuse treatment, offenders typi- cally require the following services:

• Detoxification

• Screening and assessment (see chapter 2)

• Treatment for co-occurring mental disor- ders (see chapters 2, 3, 4, and 6)

• Treatment for physical health issues

• Family-related services such as visitation, childcare, and reunification

• Case management

• Legal assistance

• Vocational skills development and employment

What varies from offender to offender is the emphasis placed on particular needs and the treatment and related services available to meet those needs. The following highlights some of the more salient issues offenders face—detoxification, homelessness, and life skills. For more information on assessing and meeting basic needs, see chapters 2, 3, and 4.

Detoxification Chapter 2 provides information on how to identify offenders in need of detoxification services. However, even if a counselor does not perform screening and evaluation, he or she should be aware of the signs and symp- toms of withdrawal. Sometimes offenders in need of detoxification are not identified at intake because they lied about the extent of their substance use, there was no reason to suspect substance dependency, or withdrawal symptoms were mistaken for mental illness. Offenders who experience withdrawal without medical attention are at risk for serious health consequences, and withdrawal from some drugs (e.g., alcohol, barbiturates) even carries a risk of death.

Symptoms of withdrawal vary according to the substance abused, but signs that may be noted by the counselor include

• Anxiety, restlessness, irritability, panic attacks, insomnia

• Profuse sweating, muscle jerks, constant blinking

• Yawning, sleepiness, exhaustion, lethargy

• Depression, crying fits, disorientation

• Suicidal thoughts or behavior

For some drugs, symptoms of withdrawal can be prolonged. For example, the insomnia and

72 Chapter 5

anxiety common in people with benzodi- azepine dependency can continue for months following discontinuation of use (Federal Bureau of Prisons 2000). For offenders undergoing treatment for withdrawal, the counselor should work closely with the medi- cal team to ensure that symptoms are identi- fied and treated.

For more on information on detoxification, see chapter 2 of this TIP and the forthcoming TIP Detoxification and Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] in development a).

Homelessness The impact of homelessness on offenders varies depending on the particular setting in which they are being treated. Jails frequently work with homeless offenders; in fact, some people enter jail to get food and housing (and may enter substance abuse treatment pro- grams for the same reasons). Homelessness can be a traumatic experience, and for some clients who have had to live on the streets, jail may be the safest environment in which they have lived for some time. Those used to being homeless may need to relearn how to live their lives in a stable environment.

Some offenders may have become homeless because of their incarceration in jail or prison. Even if homelessness was not an issue when the offender was arrested, it is likely that an offender will be homeless upon release. In some instances, peo- ple who have served their full sentence (and therefore are not being released on parole) enter the community without aftercare options or any plan for housing.

Counselors should be aware that a great deal of stigma and shame is attached to homelessness, and many clients are reluctant to discuss it without prompting. Panel members have had experi- ences with clients who were will-

ing to talk about criminal activity, substance use, and past trauma before they were willing to discuss the fact that they were homeless. One way to obtain this information is to ask offenders where they lived in the month prior to incarceration or arrest and if they antici- pate being homeless upon their release. A plan should be in place to provide offenders with housing if they are leaving a prison facil- ity. In all cases, effective counselors have working relationships with personnel in hous- ing services to which to refer offenders in need of housing.

Life skills Many offenders have hidden deficits in basic life skills (e.g., knowing how to balance a checkbook, prepare a meal, accept feedback from an employer). While these deficits are as individual as the offender, the consensus panel feels that treatment programs with criminal justice clients should address a range of instrumental skills (e.g., meal preparation, money management, laundry, resume writ- ing), as well as some basic social skills, partic- ularly those needed in employment and other interpersonal situations. Counselors should observe offenders to identify problem areas.

Among the skills most underdeveloped in offender-clients are basic problemsolving skills. Because of their impulsiveness and dif- ficulty delaying gratification, many offenders are particularly poor at breaking down mod- erately complex problems into the few basic

73Major Treatment Issues and Approaches

Advice to the Counselor: Homelessness

• Offenders should be asked where they lived in the month prior to arrest.

• If offenders anticipate being homeless when they leave the prison, a plan to provide offenders with housing should be in place before their release.

• Addressing deficits in basic life skills as well as housing issues can help prevent recidivism.

steps required to get from problem to solu- tion. Practice is needed to learn clear prob- lem identification, generation of options, thinking through likely outcomes, option selection, trying out options, and reviewing outcomes.

Addressing Criminality Antonowicz and Ross (1994) address the need to prioritize treatment according to the crim- inogenic needs of criminal justice clients, par- ticularly the specific issues that brought the client to the criminal justice system in the first place. These are most often substance abuse and criminal thinking and values. This section describes the components of criminali- ty (i.e., criminal thinking, the criminal code, and manipulation), and suggests programmat- ic and clinical strategies for addressing crimi- nality in substance abuse treatment for offenders.

Criminal thinking A range of factors are associated with sub- stance use among offenders, including peer substance abuse, impulse control difficulties, trouble managing negative emotions, poor problemsolving and self-management skills, impaired moral reasoning, and cognitive dis- tortions (Wanberg and Milkman 1998). As noted, criminal thinking is especially impor- tant to address, as individuals with ingrained criminal lifestyles employ a number of cogni-

tive distortions or “thinking errors” (see Figure 5-1).

Offenders can learn to recognize thinking errors and to understand how those errors can lead to behavior that gets them into trou- ble (Wanberg and Milkman 1998). Strategies include

• Involvement in specialized therapeutic com- munity (TC) programs

• Cognitive–behavioral group interventions focused on correcting and eliminating crimi- nal thinking errors

• Self-monitoring exercises through keeping a journal and “thought logs”

• Staff and peer confrontation regarding criminal thinking patterns and related behaviors observed within treatment pro- grams (Field 1986; Wanberg and Milkman 1998)

A number of approaches, drawing largely on cognitive–behavioral methods, have also been developed in recent years to address criminal thinking, the most popular among these being Thinking for a Change, issued by the National Institute of Corrections (NIC) (Bush et al. 2000), Gordon Graham and Company’s Framework for Recovery (Graham 1999), and Wanberg and Milkman’s Criminal Conduct and Substance Abuse Treatment (Wanberg and Milkman 1998). The core components of Thinking for a Change are described below. For more information on Framework for Recovery, go to www.ggco.com/. Wanberg and

Milkman’s module is available as a provider’s guide and partici- pant’s workbook.

Criminal thinking also can be addressed using the same paradigms used in substance abuse relapse prevention. Many of the early warning signs and risk factors for relapse will be the same or very similar to those warning signs and risk factors for the client’s criminal thinking. It is important that the focus on

74 Chapter 5

Advice to the Counselor: Criminal Thinking

• Criminal thinking should be viewed as an outcome of maladaptive coping strategies rather than as a perma- nent fixture of the offender’s personality.

• Criminal thinking can be addressed using the same tools as in substance abuse relapse prevention. This includes identifying offenders’ primary thinking errors, instruct- ing clients to self-monitor when these errors occur, and providing regular feedback from peers to prevent rever- sion to criminal behavior.

addressing criminal thinking not become another way of stigmatizing criminal justice clients. Criminal thinking should be viewed as the outcome of maladaptive coping strategies rather than as a permanent fixture of the offender’s personality.

Client manipulativeness Criminal justice client manipulativeness can be addressed by identifying “criminal think- ing errors” or one of the other, similar meth- ods of identifying cognitive distortions (Wanberg and Milkman 1998). For example, a particular client may try to avoid the work of personal change by repetitively demeaning others, including the counselor. Another client may repetitively project an attitude of giving up at every small setback (“zero state”). These maladaptive and manipulative coping strategies readily undermine the treat- ment process unless they are addressed. Addressing client manipulativeness involves

• Counselor or treatment group identifying the primary thinking errors they observe

• Instructing the client to begin self-monitor- ing when these occur (journaling)

• Providing regular feedback to the client, usually from peers in a treatment group

Criminal code Offenders tend to have a shared value system that includes refusal both to cooperate with authority and to confront negative behavior by others. This “criminal code” or “convict code” is another part of criminal thinking that must be addressed in treatment. The criminal code explains why good treatment programs stressing personal accountability, peer support for change, and peer confronta- tion of negative behavior are so threatening to the offender culture. It also explains why it is often necessary to separate inmates in treat- ment in correctional institutions from the gen- eral inmate population.

Treatment staff need to pay attention to the extent to which their clients are being stigma- tized by other offenders as “snitches” or “weak” because they participate in treatment. It is sometimes necessary to remove clients from a negative situation to give treatment a chance. Sometimes, a newer treatment group might be pressured to revert to the criminal code with antisocial values predominating over prosocial values. These situations

75Major Treatment Issues and Approaches

Figure 5-1 Common Thinking Errors

Power thrust Putting people down, dominating

Closed channel Seeing things only one way

Victim stance Blaming other people

Pride Feeling superior to other people

Don’t care Feeling unconcerned about how other people are affected

Want it now Demanding gratification now

Don’t need anybody Refusing to be dependent on others for anything

Rigid thinking Thinking in black and white terms

They deserve it Believing that people have it coming

Screwed Feeling mistreated

Source: Wanberg and Milkman 1998.

require careful confrontation, limit-setting, and clear expectations with consequences by treatment staff.

Addressing Anger and Hostility Dealing with anger and hostility with criminal justice clients is much like dealing with anger and hostility with other clients. However, due to their higher incidence of antisocial person- ality disorder, criminal justice clients are more likely to use anger as a manipulative coping strategy and less likely to be able to separate anger from other feelings.

Clients may be angry for a variety of reasons, including

• Genuine feelings of being treated unfairly

• Limited affect recognition; confusing anger with other feelings

• Using anger to maintain adrenaline

• Goal-directed manipulative coping strate- gies such as deflecting attention from other issues or to keep others off-balance

Often, problems with expressed anger relate to an inability to express other feelings—a problem with affect. Interventions involve teaching criminal justice clients to recognize their affective states and to understand the difference between feelings and action. Many criminal justice clients (especially men) have

limited understanding of and insight into what they are feeling at particular points in time. The counselor’s goal, then, is to broad- en affect (emotions) identification. For a sur- prising number of offenders, feeling states ini- tially consist of “angry” and “other.” Often, what they first think is anger turns out to be frustration, hurt, loneliness, fear, etc.

Offenders who abuse substances also have a tendency to think that if they feel it, they must act on it. Learning the relationships between behavior, thinking, and feeling, and how each affects the other, is helpful to many criminal justice clients. Learning that feelings do not equal thinking or behavior can be a revelation for many offenders. Counselors should point out that feeling it doesn’t make it so, nor does it mean the client has to act on the feeling. As the Alcoholics Anonymous say- ing states, “Your feelings are not facts.”

In summary, interventions addressing emo- tions should encompass

1. Identifying the feeling(s). Maybe other feelings are involved, such as embarrass- ment or guilt.

2. Understanding clearly where the feeling is coming from. What is the real source of the anger?

3. Identifying the goals the anger is serving (e.g., deflecting attention).

76 Chapter 5

Thinking for a Change

NIC’s Thinking for a Change helps offenders learn to change criminal behaviors using three basic tech- niques:

• Cognitive self-change. Offenders learn how to examine their thinking, feelings, beliefs, and attitudes in order to understand how these factors contribute to criminal behaviors.

• Social skills development. Participants explore alternatives to antisocial and criminal behaviors. • Problemsolving skills development. Offenders integrate the skills they learn and use them to work

through difficult situations without engaging in criminal behavior.

Thinking for a Change is designed to work in a variety of criminal justice settings, and is ideally imple- mented in groups of 8 to 12. The curriculum is available online, along with more information (at www.nicic.org/pubs/2001/016672.htm).

4. Identifying the goals the anger is under- mining (e.g., staying out of jail or keeping a job).

5. Working toward taking the longer view (e.g., beginning to use a prosocial thought process to manage the anger).

Several additional strategies can help clients to recognize their feelings. For example, counselors can set boundaries on how anger and hostility can be expressed and set limits as to reasonable duration of expression of anger and hostility. Once the offender calms down, the counselor can refocus on what the client can learn from the situation and how the client can benefit in the future. Counselors can also use peers in a group set- ting to explore how the client might use anger and hostility for secondary gain. TC groups have “cardinal rules” that include no violence or threat of violence (justification for pro- gram removal if violated) that provide a safe environment for exploring anger issues. For more information on anger management, see Reilly and Shopshire (2002).

Addressing Identity Issues As offenders move through the criminal jus- tice system, important elements in their iden- ty can change. In the pretrial stage, their identity as a member of a racial or cultural group, a family member, or employee may be most prominent. In jails there is generally a more immediate crisis, as one grapples with the shame and stigma of being labeled a crim- inal and the fear of facing extensive incarcer- ation.

Criminal identity In prison, some people learn a new identity based on the prison culture in which they are involved; some prisoners learn to think of themselves as criminals. In part, this is a result of institutional pressures on them, and partly it is the result of interactions with other inmates who have accepted the persona of criminal. For offenders who enter commu-

nity supervision programs on release from prison, embedded criminal identities can pose a number of problems.

Regardless of whether the offender is in jail, prison, or under community supervision, the identity of an offender often is an issue that needs to be confronted in treatment. Those who have adopted a criminal identity need to learn new ways of thinking about themselves; those whose identity is shaken by the incar- ceration will need help coping with their crim- inal charges. An overall rehabilitation goal is to help offenders develop more prosocial identities consistent with positive social values.

Cultural identity Race and cultural background can play an important role in the life of offenders, but the dynamics of race and culture are especially pronounced in jails and prisons. In these set- tings, Caucasians often are in the minority for the first time in their lives. A number of sub- cultures are found within jails and prisons. Inmates who belong to minority groups may see correctional staff members (including treatment staff) as adversaries. Gangs repre- sent the most significant of these subcultures, at least among male populations. Gang affilia- tion can influence with whom an offender is able to socialize. Thus, treatment must take into account this aspect of the offender’s identity.

Role as a family member and/or parent Family relationships are often an important part of an offender’s life. Family can repre- sent a connection to the outside world and can be a source of stability for offenders as they move through the criminal justice sys- tem. Moreover, the quality of the offender’s relationship with his or her family can be an important factor in recovery. Slaght (1999) reported that the only independent variable related significantly to relapse at 3 months

77Major Treatment Issues and Approaches

after release to the community was whether the offender was getting along with family members. Those who were getting along very well with family members were the least likely to use drugs. Based on this, Slaght recom- mends more extensive efforts to involve fami- ly members in drug treatment.

Just as positive family relationships can foster abstinence, family connections also can be a source of confusion and worry for clients who see their role as a family member in conflict with their role as an inmate and/or criminal. This can be especially true for parents. According to the Bureau of Justice Statistics, in 1999 the majority of State and Federal prisoners reported having at least one child under the age of 18 (Mumola 2000). For many of these offenders, drug or alcohol abuse was a factor in their incarceration. For example, one in three mothers in State prison commit- ted her crime to get money for drugs, and 65 percent reported drug use in the month prior to the offense. For both mothers and fathers, 25 percent met the diagnostic criteria for alcohol abuse (Mumola 2000). In a survey of female inmates, Acoa and Austin (1996) found that nearly 20 percent of mothers were con- cerned that one or more children may have been exposed to substances in utero.

Confronting the guilt associated with their drug abuse can be important in treating par- ents involved in the criminal justice system.

These individuals often identify themselves as “bad” parents and experience a great deal of shame over how their involvement in the criminal justice system has impacted their children. While this may be especially true for mothers, fathers also have strong feelings about their role as parents and express con- cern about their children. Jeffries and col- leagues (2001) reviewed several parenting programs for male offenders. Descriptions of these programs are available online at www.vera.org/publication_pdf/fathers.pdf.

Treatment that includes other family mem- bers can be of use. In some families, more than one family member is incarcerated; treating the family can address a generational cycle of incarceration. Family treatment also can prepare inmates and their families for release. Since family problems can be a relapse trigger, Slaght (1999) recommends that offenders learn how to identify and cope with family conflicts. Substance abuse treat- ment programs also can use family involve- ment as a source of motivation. For example, extended parent–child visits can be used as a reward for good behavior.

It is important to note that family involve- ment in recovery is not always positive. Inmates, especially those with moderate to longer sentences, often can develop a false sense of “healing” of family problems. This results from a number of factors including

reduced and controlled contact with family members and the tendency of families to shelter the inmate from problems on the outside. This false sense that family relations have changed becomes a potential stressor on release, when the inmate discov- ers that the previously existing problems are still present and often worsened. It is also impor- tant to note that sometimes offenders use their families to provide them with drugs and to enable their substance abuse. Family members may also be

78 Chapter 5

Advice to the Counselor: Family Involvement

• Involving the family in an offender’s treatment can be a positive source of support. Unfortunately, however, some family members may provide offenders with drugs and be involved in criminal activity. Inmates can develop a false sense of “healing” of family problems from having reduced and controlled contact with family.

• Extended family visitation can be used as a reward for good behavior.

• On release, inmates often find that preexisting family problems are still present and often worse.

involved in criminal activity and be expected to carry on criminal activities such as drug dealing while one member is incarcerated.

Role as a person of status Prisons and jails are hierarchical societies, and men and women can attain status within a prison or jail community often using a dif- ferent set of skills and behaviors than they would use in the community. This is especially true in prisons where longer stays make sta- tus and belonging more important issues. Therefore it is possible that an offender may face a loss of status either by going to prison (and losing a job and a place in the communi- ty) or by being released from prison (where the individual may have been a leader). Providers also should be aware that the offender may have had high status and a large income on the “outside” because of criminal activity (e.g., drug dealing) and may need to deal with a loss of status when incar- cerated or resist the temptation of returning to a high-paying but illegal occupation on release. In other instances, an inmate may carry status (e.g., as a gang member) into jail or prison, and may resist treatment in order to maintain that status. Regardless of the set- ting, the consensus panel believes that treat- ment activities should include opportunities for participants to “earn” status in the program.

Addressing Denial Criminal justice clients exhibit denial in ways similar to those of other populations. For some offenders, denial is a product of their criminal thinking. The criminal justice system may help reduce denial—it is harder for an offender to deny that drugs are a problem while sitting in a cell. Treatment staff can remind clients of the reality of their legal problems as a way to break through denial.

While substance abuse treatment providers often are trained to view denial as a negative symptom of the offender’s addiction, denial may be a necessary strategy to further the

offender’s legal goals. In some situations, offenders have incentives to admit to a sub- stance use disorder even if they do not have such a disorder, so that they can avoid prison and enter a treatment program instead. Admitting to substance abuse can have legal consequences for the offender that need to be understood by treatment providers before they ask an offender to self-identify as an “addict” or “alcoholic.” It should also be noted that there are offenders who use or sell substances but do not have a substance use disorder.

Denial of criminal activity is a different, but related, issue. People may deny criminal activity even if they have dealt with their sub- stance abuse. Just because an offender is in recovery from substance abuse does not mean he or she has ceased criminal activity. Treatment providers also will find that some offenders do not believe that what they have done is criminal or, at least, do not believe it is immoral. Some (e.g., gang members) per- ceive their actions as a normal part of daily life in their community and believe that the only problem was that they got caught. They see themselves as victimized by the law, rather than as victimizers. Others admit their substance abuse and even realize that they must cease criminal activity but deny that they have to change their lifestyle (e.g., their associations, the place they live), which can contribute to relapse.

Addressing Resistance Sending criminal justice clients to treatment under threat of direct consequences with little incentive and loss of freedoms is not effective coercion. However, coercion can be very effective at getting criminal justice clients to treatment and keeping them there (Leukefeld and Tims 1988). This is best done using incentives as well as sanctions and involving some degree of choice by the client, even if leverage is present to encourage the client to make the desired choice.

79Major Treatment Issues and Approaches

When dealing one-on-one with the criminal justice client on this issue, the consensus panel suggests the following strategies:

• Avoid personalizing the situation and focus on the client’s role in forcing the conse- quence. For example, avoid phrasing that sends the message “I’m doing this to you.” Say things such as “You sort of forced the judge into giving you this consequence for using again.”

• Focus the client on the future and what she can learn from the current situation.

• Be aware of cultural differences. Clients have culturally based attitudes toward authority that can affect how they respond to coercion in treatment. For example, con- frontational treatment modalities may not be helpful for American Indians (Vacc et al. 1995).

• Approach clients with sensitivity, under- standing, and honesty. This includes paying careful attention to body language, eye con- tact, and tone of voice.

For more information on treating coerced clients, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b); the TIP includes a section titled “Motivational Enhancement and Coerced Clients” that will be of particular use in the treatment of offenders.

Addressing Guilt, Shame, and Stigma Guilt and shame may also be a major consid- eration for some criminal justice clients. Offenders new to the criminal justice system, particularly first-time offenders who have recently lost much of their social standing, may struggle with guilt and shame. In some cases these feelings are realistic and may facilitate treatment, but in other cases they may be exaggerated and interfere with sub- stance abuse treatment until they are ade- quately processed. As noted above, many offenders experience a significant amount of shame over their actions even if they are not willing to show it. Those who do not may either have an antisocial personality disorder (see p. 112 for more information) or come from criminally involved family or social net- works where criminal behavior is expected and approved; those clients may still feel shame, but it could be because they “messed up” and got caught.

Shame can be healthy, if it can motivate peo- ple to change their lives. Making amends can be a positive way to address guilt and shame and further treatment goals. Talking about feelings of guilt and self-loathing can also help an offender reduce feelings of hostility and anger. Shame and guilt, however, can also fuel denial and can make some individuals more prone to violence in order to cover up their feelings of shame. In general, female

offenders face more shame than men or are, at least, more con- scious of the shame they feel.

The stigma associated with crim- inal behavior and substance abuse also can be very powerful but is less useful as motivation for clients. The criminal justice system does much to stigmatize the offenders in the system, and the people involved in that sys- tem (whether they be corrections officers or inmates) often rein- force guilt, shame, and stigma.

80 Chapter 5

Advice to the Counselor: Addressing the Coerced Client

• Approach coerced clients with understanding and hon- esty, paying careful attention to body language, eye con- tact, and tone of voice.

• When dealing one-on-one with the coerced client, focus on the client’s role in forcing the consequence, with statements such as “You sort of forced the judge into giving you this consequence for using again.”

• Focus the client on the future and the difference treat- ment can make.

Stigma also comes from outside the criminal justice system (e.g., family, mass media, soci- ety). While it is important for offenders not to forget their past, it is not necessarily helpful that society does not allow people to move on or accept that they have paid their debts. It is also important for offenders to have appro- priate role models who have overcome the stigma of a criminal past and a history of sub- stance abuse in order to achieve something in their recovery.

While there has been some reduction of stigma attached to substance abuse and mental ill- ness in recent years, the stigma associated with arrest, convic- tion, and incarceration remains very strong. Societal change occurs slowly, but treatment providers can help the situation by not burdening clients with additional stigma because they are involved in the criminal jus- tice system. The consensus panel suggests that if crime is part of addictive behavior, then criminal behavior can be seen as another manifestation of a sub- stance use disorder. Treatment

providers need not condone an offender’s past criminal activity, but they should be able to accept it as part of the client’s past and not a permanent character flaw or insurmount- able obstacle to recovery.

Establishing Boundaries Counselors’ methods for establishing a rela- tionship with clients vary according to the set- ting. It is much more difficult to develop a

81Major Treatment Issues and Approaches

Sealed Records

A criminal record follows offenders long after they serve their time in prison. Many recovering individuals find that, despite their best efforts, the stigma of their criminal records limits their options. A 2001 CSAT initiative, Rehabilitation and Restitution, contains a component to help recovering offenders get their crimi- nal records sealed. Additionally, participating programs may offer

• Comprehensive assessments

• Individualized service plans

• Case management

• Continuum of substance abuse treatment services

• Support in obtaining a GED or other necessary education

• Job training, placement, and retention programs

• Continuum of supervision, aftercare, and continuing care programs

CSAT’s cooperative agreement initiative is aimed at improving the likelihood of successful reintegration. Programs funded through the initiative will compare the success rates of those who receive additional assistance with those who receive whatever help is usually offered to recovering offenders.

Advice to the Counselor: Establishing Boundaries

• No matter how much empathy they feel for offenders, counselors need to remember that they represent the criminal justice system.

• Counselors’ self-disclosures can be helpful when balanced by appropriate boundaries.

• Offenders are often deft at conning a counselor into doing small and seemingly meaningless things for them, but this is often a first step in an unhealthy alliance that can be used against the counselor at a later date. A well- trained counselor can confront the offender and turn the attempted manipulation into a step for developing a stronger treatment alliance.

relationship in prisons or jails than in the community because boundaries and rules limit how psychologically close one can get to incarcerated offenders. For example, while eliciting emotional responses is quite useful in psychotherapy, corrections staff generally see this as a problem to be avoided. In these set- tings there needs to be careful supervision to evaluate how closely counselors and clients are interacting.

Because boundaries between staff and clients have a special significance in criminal justice settings, treatment staff need to be especially vigilant about self-disclosure. The counselor needs to ask him- or herself whether a per- sonal disclosure is going to make a difference for the client and not just for the counselor. For example, using one’s personal experience as guiding life lessons can add credibility and be helpful on a more personal level, but recent experiences that may expose too much vulnerability should be avoided. Also, recov- ering staff in TCs who often share personal experiences have found the practice to be beneficial when balanced with appropriate boundaries. Counselors also should not asso- ciate with clients to the detriment of their relationship with corrections and treatment staff; no matter how much empathy they feel toward offenders, counselors need to remem- ber that they represent the criminal justice system. Offenders are often deft at conning a counselor into doing small and seemingly meaningless things for them, but this is often the first step in an unhealthy alliance that can be used against the counselor at a later date. Alternatively, a well-trained counselor can often confront the offender and turn the attempted manipulation into a step in devel- oping a stronger treatment alliance.

Creating a Therapeutic Alliance While it is not always easy, given the bound- ary issues that exist in criminal justice set- tings, the creation of a therapeutic alliance is very important when working with this popu-

lation. Of course, the ability to create this alliance and its relative importance varies according to staff ability, experience, and training. In jails, it may be less crucial because clients may remain in treatment only a short time. It may, however, be most critical in community supervision settings if clients are engaged in outpatient treatment. In resi- dential programs, such as therapeutic com- munities, peers play a larger part in the treat- ment experience, and the client’s relationship with his or her peers is often as important as or more important than the relationship with the counselor.

Relationships with criminal justice staff are often quite important in the therapeutic pro- cess. This is especially important for offend- ers under community supervision, as their alliance with their probation or parole officer is critical. In a prison or jail setting, it also helps to include corrections staff as part of the treatment team, but clients should be told if this is going to be the case. When probation officers or corrections staff members are part of the treatment team, roles need to be very clearly defined. Because they may lack expe- rience in treatment, corrections officers can become too involved in the treatment process and become overly distraught over treatment failures. In order to operate within a prison or jail, corrections staff need to maintain a certain degree of distance from offenders as well as keep their respect. The consensus panel recommends that treatment programs that are going to involve corrections staff or probation officers should provide extensive cross-training between corrections and sub- stance abuse treatment staffs. The legal issues surrounding confidentiality, for example, are a suitable subject for cross-training.

Striving for counselor credibility Counselors working in any treatment setting need to maintain credibility with their clients.

If offenders believe that treatment staff are competent, they will be more influenced by

82 Chapter 5

the treatment and less likely to return to incarceration. Research by Broome and col- leagues (1996a) showed that high self-esteem and high ratings of counselor competence were asso- ciated with a significant reduc- tion in recidivism by probation- ers ending their treatment. Strauss and Falkin (2000) found similar results with a cohort of female offenders. Their data indicate that clients who suc- cessfully completed treatment had more favorable perceptions of staff within the first 2 weeks of treatment than those who did not.

Striving for cultural competence Cultural competence is an important factor in developing a counselor–client relationship. Programs should have a cultur- ally diverse staff that reflects the diversity of the population they serve; however, that is not always possible. What is possible is that staff be trained to understand cultural issues affecting the populations in the area in which they work. Cultural issues reflect a range of influences and are not just a matter of ethnic or racial identity (e.g., Ohio prisons have a large number of inmates from Appalachia, and staff there need to understand that cul- ture). Special training programs can be devel- oped to help counselors attain cultural com- petence for the cultures the agency serves. (The forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development b] provides indepth information on developing cultural compe- tence and providing culturally competent treatment.)

Designing Treatment to Reflect the Stages of Change The concepts behind the stages of change model of recovery (Prochaska et al. 1992) were introduced and summarized in chapter 3. While these are important concepts in recovery generally, they are particularly rele- vant in the treatment of criminal justice clients because so many of these clients are in the early stages of change. Figure 5-2 (next page) summarizes treatment strategies based on the offender’s stage in recovery.

Counselors with criminal justice clients often find they spend much of their time working in the precontemplation and contemplation stages. This can be discouraging to some, but the trade-off is that this is important work

83Major Treatment Issues and Approaches

Advice to the Counselor: Establishing Counselor Credibility

• Avoid making promises that you foresee being unable to keep. If you are unable to keep a promise, be clear as to why you cannot do so and accept the consequences.

• Demonstrate the attitudes and behaviors you are trying to get clients to implement (credible staff are those who do as they say).

• Show a positive attitude toward colleagues, the pro- gram, one’s family, and so on.

• Work to have the client respect who you are, even if he does not like what you represent.

• Ensure that you maintain the respect of your supervisor and other staff (including corrections officers and proba- tion officers). Credibility with offenders is affected by their observations of the counselors’ interactions with other staff, and clients do watch staff closely.

• Clearly articulate roles and boundaries. Inmates often see treatment staff as potential inroads into all areas rang- ing from personal property issues, to job assignments, to case management concerns. Treatment staff need to clearly define their role and limits or they quickly find their credibility lost because inmates interpret the staff’s inability to correct a nontreatment issue as a lack of con- cern or caring.

that reduces both crime and the number of crime victims, in addition to rehabilitating offenders.

Program Components and Strategies The initial goals of substance abuse treatment are to “get them there” (engagement) and to “keep them there” (retention). This section addresses programmatic strategies to foster both engagement and retention and discusses other program components that promote effective substance abuse treatment for crimi- nal justice clients.

Engagement Arrest and incarceration can provide an important opportunity to identify substance abuse and other psychosocial problems, to

provide stabilization of acute needs (e.g., detoxification from alcohol or opioids, medi- cation for psychotic or depressive symptoms), and to engage offenders in substance abuse treatment services (Peters and Kearns 1992). Jails, prisons, and community diversion or supervision programs often serve as the first point of contact for offenders who have sub- stance abuse problems. Motivation to enter treatment frequently occurs at particularly stressful times such as after being arrested, after one’s children have been removed by authorities, or following an overdose or a “bad high.” Substance abuse treatment staff need to watch for these opportune times and respond quickly so that the client can be engaged in treatment while the motivation is still strong. Most of these individuals have not had previous contact with substance abuse treatment agencies, and their first involve- ment in treatment services is frequently while in jail or prison (Mumola 1999).

84 Chapter 5

Figure 5-2 Strategies for Working With Offenders Based on Their Stage in Recovery

State Description Strategies

Precontemplation Unaware of substance abuse problems

Instill discomfort in a supportive manner. Increase the client’s ability to recognize problems with current behavior and dissonance with future goals.

Contemplation Awareness of sub- stance abuse problems

Tip the balance. Elicit from the client the reasons to change, and the risks of not changing. Support prosocial thinking from the client.

Preparation Decision point Plan the action. Help the client determine the best course of action. These plans are individualized as they vary consider- ably from client to client.

Action Active behavior change

Help the client take steps toward change. Begin shifting from external motivators to internal motivators by supporting the client’s self-efficacy for change.

Maintenance Ongoing preventive behaviors

Relapse prevention focusing on coping mechanisms and avoidance of triggers. Monitoring of attitudes and behaviors that can lead to relapse. Assisting the client in making lifestyle changes and encouraging the client to assist others who are in the recovery process.

Program incentives and sanctions to encourage engagement In the community, the usual sanction for refusing to participate in treatment is loss of freedom—often incarceration. In jails and prisons it usually involves longer incarcera- tion times. At the point of decision of whether or not to participate in treatment, the offend- er usually faces more sanctions than incen- tives to participate, and the sanctions may be severe.

A key point in “getting them there” is to be sure that disincentives to program participa- tion are minimized. For example, if offenders lose freedoms or have worse housing (in insti- tutions) as a result of program participation, many will not give treatment a chance.

Enhancing motivation While legal pressures may be sufficient to get a client into treatment, engagement is neces- sary if the client is to become motivated to commit to change and maintain recovery (Hubbard et al. 1988). Therefore, treatment programs need to be aware of the common characteristics of clients who leave treatment early and use this knowledge to develop approaches that motivate these clients to stay in treatment.

In a study of offenders on probation, Broome and colleagues (1996a) looked at three client background factors that are associated with treatment outcomes to see if they had an effect on establishing therapeutic relation- ships. Recognition of the existence of a sub- stance abuse problem was associated with a positive therapeutic relationship and engage- ment in treatment, while the degree of peer deviance in the client’s social network and family dysfunction was not. The fact that recognition of substance abuse problems was a positive indicator for successful engagement in treatment lends support to the use of moti- vational approaches that help the client rec-

ognize he or she has a problem with substance abuse.

Effective Use of Coercion at the Program Level “Coercion” means using incentives and sanc- tions to encourage program participation. In some jurisdictions, coercion may come in the form of legal mandate to treatment. This rarely affects offenders already sentenced to prison, but it often affects clients under com- munity supervision who may need to be involved in treatment as part of their proba- tion or parole. Clients under community supervision also may elect to enter treatment to avoid harsher alternatives (such as invol- untary admission into a mental hospital) or negative repercussions (such as losing custody of one’s children). Individuals convicted of driving while under the influence may be required to complete a psychoeducational class to retain their driver’s license. The California initiative known as Proposition 36 offers a choice between incarceration and probation with substance abuse treatment to first- or second-time offenders convicted of nonviolent drug possession charges (see chap- ter 11 for more information). Arizona has enacted a similar law, and other States have them under consideration. Offenders may also receive pressure from other governmen- tal agencies (e.g., child protective services agencies) to enter or continue treatment, as part of community supervision or while in jail or prison. Not all forms of coercion are explicit for clients involved in the criminal justice system; people may receive reduced sentences or avoid incarceration in a higher security facility if they enter treatment.

Retention in Treatment Roberts and Nishimoto (1996) studied reten- tion in treatment among a group of women who were cocaine dependent, many of whom were under criminal justice supervision. The type of treatment services provided to the women made the largest difference in reten-

85Major Treatment Issues and Approaches

tion. The authors concluded that the intensity of the treatment, its structure, and the exis- tence of woman-focused programming engaged the clients. However, greater levels of severity of a substance abuse problem also predicted shorter stays in treatment, and pre- vious substance abuse treatment increased slightly the risk of dropping out.

Other research has shown that early dropout from treatment in criminal justice settings is correlated with having a history of psychi- atric treatment, high levels of anxiety and depression, unemployment immediately prior to sentencing, cocaine dependence, lower lev- els of self-efficacy, and social networks that

demonstrate low levels of social conformity (Hiller et al. 1999b). These authors found that the strongest predictor of treatment dropout was a high score on a criminality classification system they developed based on the Lifestyle Criminality Screening Form (Walters et al. 1991) that measured aspects of an offender’s lifestyle related to criminality (e.g., irresponsibility, self-indulgence, inter- personal intrusiveness, social rule-breaking). Lang and Belenko (2000) found that offenders in a diversionary treatment program for felony drug offenders who completed treat- ment had higher levels of social conformity and more friends, fewer drug felony convic-

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Does Coerced Treatment Work?

In a review of 11 coerced treatment studies conducted over 20 years, Anglin and colleagues (1998) found that, while coercion was generally effective, the results were far from unequivocal, with five studies reporting that coerced clients did better, four studies reporting no difference, and two studies reporting that the coerced clients did worse. It is important to note, however, that in the 11 coerced treatment studies reviewed, none directly assessed the motivation of the clients (Farabee et al. 1998). In most cases, involuntary or coerced status of clients was inferred from criminal justice status at intake. Many clients whose treatment was coerced say they would have entered treatment without legal pressure to do so (Marlowe et al. 1996). Only about a third of those who entered coerced treatment for cocaine abuse said that legal coercion was a reason for entering treatment. Rather, psychological, financial, social, familial, and medical pressures exerted more influence in the decision to enter treatment (Marlowe et al. 1996).

While some critics have argued that treatment will be ineffective unless a client is motivated to change his or her substance abuse behavior, treatment itself can alter the client’s motivation. In fact, an impor- tant indicator of an effective program is its ability to engage and retain clients who initially join under coercive pressures. The major difficulty, then, is often a matter of getting resistant clients to enter treat- ment, and coercion has been shown to increase the likelihood of an offender’s entering treatment (Anglin et al. 1998).

Coercion such as that from the criminal justice system can play an important role in making sure the client enters treatment, but it will be internal motivation that predicts whether the client will stay in treatment and have a positive outcome. Knight and colleagues (2000) showed that external legal pressure and internal motivation are positively and independently related to retention in treatment. The authors recommend targeting those with low internal motivation for an intervention to increase readiness.

Research also suggests that in the absence of leverage imposed by the criminal justice system, offenders have a poor record of retention and graduation from substance abuse treatment programs. Moreover, outcomes for offenders who receive coerced treatment are as good as or better than for other partici- pants in treatment (Hubbard et al. 1988a; Miller and Flaherty 2000). Leverage through the criminal jus- tice system also helps retain offenders in treatment over time (Miller and Flaherty 2000), which tends to reduce the rate of criminal recidivism.

tions, less involvement in psychiatric treat- ment, less income from drug dealing, less unprotected sex, and fewer injuries from gun- shots or stabbings.

While many of the factors that correlate with treatment dropout cannot be altered, the con- sensus panel suggests that some changes to treatment programs can be developed based on these studies. For one, there seems to be general agreement that a client’s friends can have a good deal of influence on whether that person will successfully complete treatment. Developing positive peer networks should therefore be a priority for retaining offenders in treatment.

A history of co-occurring mental illness, as demonstrated through a history of mental health system involvement, can have a signifi- cant negative effect on treatment retention. High rates of co-occurring mental illness have been documented in the offender population (estimated to be 7.4 percent in Federal pris- ons, 16.2 percent in State prisons, and 16.3 percent in jails) (Ditton 1999), suggesting a need for treatment programs tailored for offenders with co-occurring disorders in order to reduce dropout rates.

The consensus panel also recommends that coerced individuals be mainstreamed with noncoerced clients where possible—such as in community settings—and should not be sepa- rated into different treatment tracks. Coerced treatment is much less likely to work if only similarly coerced individuals participate in the program. Because research showed that coerced treatment can be effective under some circumstances, some criminal justice systems developed new programs for these clients that did not build on existing pro- grams; clients in these programs do not seem to have fared as well because they lacked community support from clients who were committed to treatment. It is not always clear that treatment models are followed accurately (Farabee et al. 1999). Administrators should avoid creating coercive programs with mini- mal resources.

There is a risk that treatment could become overly coercive and susceptible to charges of cruel and unusual punishment. It is impor- tant that participants in treatment be offered the opportunity to leave the program after a minimum time period (e.g., 90 days). The use of experienced outside contractors and recov- ering staff can help reduce the mistrust.

Incentives and sanctions to improve retention Once the offender enters treatment, more options usually become available for creative use of incentives and sanctions to keep the offender in treatment. It is important to con- tinue to push for a preponderance of incen- tives over sanctions to motivate offenders (Gendreau 1995). Because of the manipula- tive coping strategies and evidence of criminal thinking that bombard treatment staff daily, it is all too easy to focus on the negative behaviors instead of “catching people in the act of doing good work.” But positive rein- forcement is relatively more powerful than sanctioning in changing behavior as well as other aspects of personal growth.

The types of incentives to use are limited only by creativity. Beyond reduced supervision, other incentives can be greater access to other services (e.g., employment training or improved housing), higher status within the treatment group or community, or even varia- tions on a token economy can be considered. The point is to continue to refocus on rein- forcing desired behavior, look for additional ways to motivate the clients from a positive perspective, and to remember that most peo- ple begin and sustain personal change out of external motivation (the internalized motiva- tion comes later).

The key points in effective use of incentives and sanctions are:

• Emphasize incentives over sanctions. Gendreau (1995) has suggested that 4:1 is optimal.

87Major Treatment Issues and Approaches

• Sanctions should be applied as rapidly as possible. The longer the time period between the undesired behavior and the consequences, the less effective the conse- quences.

• Repetitive use of mild sanctions (implement- ed quickly) is more effective than repetitive threats of sanctions followed by an intensive sanction (e.g., incarceration).

• Be creative with incentives.

• Treatment staff and criminal justice staff should collaboratively apply incentives and sanctions.

Prosocial Activity Prosocial activity is any positive activity. In other words, criminal justice clients will do better in treatment when kept busy doing any positive activity. Most criminal justice clients tolerate boredom poorly. This is probably partly due to the high incidence of antisocial personality disorders and attention deficit disorders within this population (Jemelka et al. 1994; Wender et al. 2001). Offenders tend to demonstrate high excitement needs coupled with poor delay of gratification (Field 1986). Without positive activity, criminal justice clients tend to use unstructured time for anti- social thinking and behavior. Therefore, regardless of content, the consensus panel believes that treatment programs need to be heavily structured, particularly for clients who are early in the change process.

Staff Modeling Accountability Criminal justice clients are particularly sensi- tive to what staff actually do, in contrast to what staff say. Words about personal accountability with this population will have only modest impact unless staff are willing to model the behavior and hold themselves to the same standards. The modeling of this behavior, of insisting on demonstrating one’s accountability instead of waiting for others to demand it, can be very powerful in helping criminal justice clients change. This is anoth- er point of collaboration between treatment

staff and criminal justice staff, as both need to model personal accountability in their behavior.

Peer Support and Feedback Peers usually have more opportunity than staff to observe each other’s behavior. Peers using a group treatment modality have the capacity to give more immediate feedback for positive steps to change and for negative thinking and behavior. Peers can often give feedback in ways that the client can more readily assimilate. Criminal justice clients often quickly and accurately see the relapse signs in others well ahead of the time they are able to see relapse signs in themselves. Using peer support and feedback also serves to pre- pare incarcerated criminal justice clients for using peer support organizations in the com- munity.

Program Phasing Many criminal justice clients have little expe- rience with success with prosocial endeavors. Dividing programs into identifiable phases can provide markers of accomplishment and progress and focuses treatment efforts at steps along the way. Typically, residential programs include orientation, treatment, and reentry phases.

Self-Management Skills— Relapse Prevention Once personal change occurs during treat- ment, a sustained effort is required to main- tain that change, namely relapse prevention and recovery planning. Relapse prevention is “a systematic method of teaching recovering patients to recognize and manage relapse warning signs” (Gorski and Kelley 1996, p. 15). For more on relapse prevention for crim- inal justice clients, see the Technical Assistance Publication Series Number 19: Counselor’s Manual for Relapse Prevention with Chemically Dependent Criminal Offenders (Gorski and Kelley 1996).

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89Major Treatment Issues and Approaches

There are several advantages to using relapse prevention as a general approach throughout criminal justice programs:

• Relapse prevention is a key issue for com- munity supervision. Beyond the obvious applicability of self-management training to offenders, this work provides key informa- tion to parole and probation officers. If the supervision officer knows that a primary overt relapse sign for a particular offender is isolating in his room, for example, the officer has critical supervision information. Knowing an offender’s early warning signs for relapse is probably as important to supervision as employment and living situation.

• Relapse prevention emphasizes taking responsibility for oneself. Relapse preven- tion work makes it difficult for the offender to blame others. Self-management training puts responsibility squarely on the individ- ual. The occurrence of a partial or full relapse is a signal that the individual has more work to do in developing or perform- ing his own relapse prevention and recovery plan. Relapse prevention work, then, can be a primary means of moving from neces- sary external controls (on the offender) early in treatment to the needed internal controls (from the offender) later in treatment.

• Relapse prevention work emphasizes the long-term nature of many disorders. Many major life problems, such as addictions, are life-long problems, requiring continuing work by the indi- vidual. The concept of relapse prevention implicitly commu- nicates this point to criminal justice clients.

• Relapse prevention work is easy to communicate. Warning signs in the individual’s behavior, and specific actions by the individual in response to those signs are easy to com- municate between corrections program staff, offenders,

supervision officers, and others in the offender’s support network. Relapse pre- vention plans aid communication from insti- tutional programs to community supervi- sion and to community programs.

• Relapse prevention is applicable across the- oretical perspectives. Practitioners from the theoretical perspectives of behaviorism and disease concepts are currently using relapse prevention and recovery planning tech- niques with equal facility. Relapse preven- tion strategies seem to ring true regardless of beliefs about the etiology of addictions or criminality.

• Relapse prevention is a unifying concept across programs. Whether the problem is alcohol abuse, drug abuse, mental illness, sex offending, or criminality generally, the same basic process seems to occur in relaps- es, and the same basic strategies seem to be needed in recovery. Relapse prevention work therefore offers a unifying concept and means of communication across types of programs and service populations.

Spiritual Approaches Spiritual approaches have been used in com- bination with substance abuse treatment ser- vices and can provide powerful tools for some to achieve sustained abstinence. There are, however, limitations to what can be done in a public institution such as a jail or prison. While a distinction should be made between “spiritual” and “religious” practices (the for-

Advice to the Counselor: Spiritual Approaches

• Spiritual approaches can provide powerful tools for some to achieve sustained abstinence. Counselors can refer clients to the religious leaders of their choice for addi- tional counseling, or to voluntary 12-Step groups that do not explicitly endorse any one religion.

• Rituals and ceremonies can be used to mark positive events.

• Providing a time and a suitable place can promote indi- vidual meditation, reflection, or prayer.

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mer being concerned with one’s own identity and a connection to a greater whole, the lat- ter involving the formal practice of a system of beliefs), such a distinction is not always perceived by criminal justice authorities. Because of issues concerning the separation of church and State, it can be difficult for treat- ment programs to provide any kind of specific religious activities. However, treatment providers can refer clients to the religious leaders of their choice for additional counsel- ing. Treatment programs can also accommo- date voluntary 12-Step groups that do not explicitly endorse any one religion.

To provide inmates in jails and prisons with opportunities for spiritual growth, programs can be creative to avoid promoting religion while still facilitating spiritual practices. Some spiritual practices, such as American Indian sweat lodges, have been instituted on the grounds that they are an important cul- tural activity. Some prison programs use ritu- als to mark certain events (which provide a way for people to express themselves without using words). Rituals and ceremonies, even if they are as simple as having a meal together, can be very important for these clients because they do not have positive rituals in their lives. The only ceremonies they may have experienced may revolve around gang activity or substance abuse. Other suggestions for promoting spiritual practices include des- ignating an area for meditation and acknowl- edgements of achievements. Providing a place for such activities is an important step in pro- moting them. It can also be helpful to sched- ule times for meditation or silent reflection.

The offender-client should be encouraged to become involved in the spiritual and religious practices with which he or she is most com- fortable. Jails and prisons should enable offenders to receive spiritual guidance from religious figures of all persuasions. Clients should be encouraged to connect with the reli- gious or spiritual tradition with which they associate most closely and to think about how that tradition can help them understand their own lives and what may be missing in them.

Interest in faith-based substance abuse treat- ment programs has opened avenues for treat- ment improvement that have been less acces- sible. Many of the “transformational” aspects in religion are similar to effective treatment components, especially relevant in self-help and therapeutic community approaches. Some examples of the common elements include the concept of transformation, credi- ble role models, behavioral rules, the central- ity of positive social values, community mem- bership and participation, rituals and cele- brations, and stages of change. In addition, consideration of a faith-based perspective offers additional support for treatment that is not usually considered, such as inviting an offender’s church of choice to consult and provide resources for the postrelease plan- ning process.

Conclusions and Recommendations The consensus panel believes that several points and recommendations in this chapter deserve highlighting, as follows:

• Whenever possible, treatment should be modified as needed to meet the individual client’s specific needs. A thorough client assessment covering multiple dimensions will enable treatment providers to deter- mine what modifications to treatment are required.

• Individual needs should be considered in adapting the sequence, focus, and intensity of treatment.

• It is important for offenders to have appro- priate peer and staff role models who have overcome the stigma of a criminal past and a history of substance abuse. Provisions should be made whenever possible to allow criminal justice programs to hire staff who are ex-offenders and who are in recovery. Treatment programs have found it useful to maintain a blend of recovering and non- recovering staff.

91Major Treatment Issues and Approaches

• While legal pressures may be sufficient to leverage a client into treatment, specific engagement strategies are necessary if the client is to be motivated to commit to change and to maintain recovery.

• Anxiety, guilt, and remorse related to past substance abuse and criminal behavior can be productive in motivating offenders to change their lives. Making amends to those who have been harmed by past behaviors is one strategy that can be used to positively address these emotions.

• There is a risk that treatment could become overly coercive and susceptible to charges of “cruel and unusual punishment.” It is important that participants in treatment be offered the opportunity to leave the pro- gram after a minimum period of time (e.g., 90 days).

• Internal motivation for treatment is a better predictor of retention than external motiva- tion. The panel recommends targeting those with low internal motivation for an inter- vention to increase readiness.

• Motivation to enter treatment frequently occurs at particularly stressful times such as after being arrested, after one’s children have been removed by authorities, or fol- lowing an overdose or a “bad high.” Substance abuse treatment and criminal justice staff should watch for these oppor- tune times and respond quickly so that the client can be engaged in treatment while their motivation is still strong.

• While clients in criminal justice settings are often coerced and resistant to treatment, they can become invested in treatment through the use of motivational interviewing and similar techniques.

• Clients who agree to enter treatment may be seen as “traitors” by other offenders, as the prison culture makes it a point to resist anything that is seen as a further attempt to control the lives of inmates. For this rea- son, it is useful to provide treatment ser- vices in residential areas or separate pris- ons that are isolated from the general inmate population.

• In jurisdictions that involve probation/ parole officers or corrections staff in treat- ment team activities, roles need to be very clearly defined. Criminal justice staff who do not have treatment-related experience or specialized training can become overly involved in the treatment process and over- ly invested in treatment issues.

• Criminal justice professionals have been effectively involved in facilitating psychoed- ucational groups and other treatment activ- ities and are often included in treatment teams and treatment and discharge plan- ning. Criminal justice professionals provid- ing group treatment services should receive specialized training in therapeutic tech- niques and treatment approaches and should consider obtaining substance abuse certification and licensure.

• Many correctional treatment programs in jails and prisons have found it useful to establish co-coordinators from both treat- ment and correctional/security systems. These arrangements provide a sense of joint “ownership” of treatment programs, enhance program credibility among correc- tional officers, and provide an effective mechanism for addressing critical incidents and solving problems that affect both treat- ment and corrections staff.

• To operate within a prison or jail and main- tain inmates’ respect, corrections and treat- ment staff need to maintain a certain dis- tance from offenders. Cross-training can assist staff in defining appropriate “bound- aries” that should be maintained in rela- tionships with inmates, and to identify related situations that can compromise the effectiveness of security/public safety and treatment operations.

• Treatment providers need not condone an offender’s past criminal activity, but they should accept it as part of the client’s past, and not a permanent character flaw or insurmountable obstacle to recovery.

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6 Adapting Offender Treatment for Specific PopulationsIn This

Chapter… Treatment Issues Related

to Cultural Minorities

Women’s Treatment Issues

Men’s Treatment Issues

Working With Violent Offenders

Treatment Issues Based on Client’s Sexual

Orientation

Treatment Issues Based on the Client’s

Cognitive/Learning, Physical, and Sensory

Disabilities

Treatment Issues for Older Adults

Treatment Issues For Clients From Rural Areas

Treatment Issues For People With Co-

Occurring Substance Use and Mental Disorders

People With Infectious Diseases

Sex Offenders

Conclusions and Recommendations

Overview Certain criminal justice system populations may be recognized as having specific needs; the consensus panel recommends that whenever possible, treatment be modified to meet those needs. A thorough client assessment will enable treatment providers to determine what modifications to treat- ment are required. However, the panel also recognizes that in order to explain different types of treatment modifications and the need for those modifications it is necessary to group clients according to certain socially defined categories that mark their relationship to a dominant identity. This chapter provides a basic overview of treatment needs of offenders belonging to subpopulations including women; men; violent offenders; gay, lesbian, and bisexual offenders; clients with physical and sensory disabili- ties; older adults; people with co-occurring mental and substance use dis- orders; people with infectious diseases; and sex offenders.

Treatment Issues Related to Cultural Minorities There is no denying that the ethnic and cultural composition of offender populations is quite different from that of society as a whole. African Americans are disproportionately represented in jails, prisons, and community supervision programs in comparison with their numbers in the general population. They represented 39.2 percent of the jail popu- lation and 44.1 percent of the prison population in 2003, 41 percent of those on parole, and 30 percent of those on probation. According to the 2000 Census, however, those who said they were African American alone or in combination with one or more other races represent only 13 percent of the U.S. population. Hispanics/Latinos, of any race, are also somewhat overrepresented, representing 15.4 percent of the jail popula- tion and 19.0 percent of the prison population in 2003, but only 13.3

percent of the U.S. population according to 2002 Census data (Ramirez and de la Cruz 2002). Caucasians are underrepresented at each stage of the criminal justice process, making up only 43.6 percent of the jail popu- lation and 35 percent of the prison population in 2003, 40 percent of those on parole, and 56 percent of probationers in 2003, but 77.1 per- cent of the U.S. population (Glaze and Palla 2004; Harrison and Beck 2004; Harrison and Karberg 2004; U.S. Census Bureau 2001).

McKean (1994) summarizes four somewhat overlapping theoretical perspectives to explain why certain racial or ethnic groups are over- represented among offenders:

• Social isolation

• Social disintegration

• Resource deprivation

• Violent cultural orientation

These theoretical stances inform substance abuse treatment as well. The social isolation model states that the dominant group will always choose to maintain a social distance between itself and minority groups, and to this end may employ discriminatory laws and policies. Social disintegration models look at how weakened informal and institutional social controls lead to increased crime. The resource deprivation theory emphasizes that economic variables such as unemployment, poverty, and income inequality are associated with crime. The idea of a subculture of vio- lence implies that violent interactions are more accepted among some groups than oth- ers, for example in gang culture.

In a study of Alaska Native men, Glass and Bieber (1997) found criminal activity to be related to social disintegration caused by acculturative stress. This stress develops when members of a minority culture are pres- sured to adapt to a dominant culture. The bicultural individuals in their study had the highest levels of acculturative stress and vio- lent behavior and seemed more prone to iden- tity issues, unstable interpersonal relation- ships, and unstable emotions. The authors

surmise that these individuals are not accept- ed in either culture and that their efforts to walk in both worlds contribute to their stress.

The forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] in development b) provides detailed information on adapting treatment to specific cultural populations, and, while it is not ori- ented toward offenders in criminal justice set- tings, much of what it has to say will apply here as well. There are not, however, many culturally specific programs operating in the criminal justice system, and there also are limited data concerning the benefits of cultur- ally competent services in these settings. This is certainly an area that requires more research.

Longshore and colleagues (1998) have studied treatment motivation among African- American detainees who used drugs and had never been in substance abuse treatment. Of all the factors they studied, “problem recog- nition” was most clearly associated with moti- vation for treatment, and that recognition was strongest among those who more strongly endorsed Afrocentric values such as commu- nity, spirituality, collective self-esteem, and conventional family roles. Incorporating these values into treatment may therefore improve treatment outcomes. For example, it could be more beneficial to emphasize the prosocial reasons for stopping substance use than the negative effects of continuing use, to include family counseling in treatment, and to view recovery as benefiting the community, not just the individual. Compared to clients in traditional programs, those in Longshore’s culturally congruent treatment were more involved in the experience, were more forth- coming in their self-disclosures, and partici- pated more actively. They also reported more motivation to seek help (Longshore et al. 1998).

The consensus panel recognizes that it is extremely difficult, however, to create a cul- turally specific program within a prison or

94 Chapter 6

jail given the variety of populations who enter the facility and the need to provide equal lev- els of treatment for all offenders. Culturally specific programs also require from clients a certain level of commitment to their culture that cannot be assumed for all members of a particular group.

Substance abuse treatment requires two-way communication of vital information including instructions, treatment expectations, personal information, and expressions of emotions. In a criminal justice setting, where the counselor represents the same institutional forces that have convicted and imprisoned the client, the levels of distrust and possibilities for misun- derstanding are magnified. While all correc- tional staff members (including counselors) are seen, to some extent, as representatives of the dominant culture, the possibilities for misunderstanding can increase when client and counselor are from different ethnic or cultural backgrounds. These misunderstand- ings can jeopardize the client’s chances for success in treatment. It is the counselor’s job to be aware of and sensitive to the values, biases, and assumptions that his or her cul- ture has created in matters of communica- tion, therapeutic style, and interpersonal con- tact and how they affect his or her ability to provide culturally competent services to clients. The most common misunderstandings in counseling originate in culture, socioeco- nomic class, and language (Sue and Sue 1999). (See the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development b].)

Women’s Treatment Issues In 1998, an estimated 950,000 women were under supervision by correctional agencies, with 85 percent on probation or parole in the community. These women were mothers to about 1.3 million children under age 18. Forty-four percent of them, across settings, reported that they had been physically or sex- ually assaulted at some time during their lives (Greenfeld and Snell 1999).

The percentage of women in the criminal jus- tice system has increased in the past decade— in jails it has risen from 10.2 to 11.9 percent (Harrison and Karberg 2002). The average annual percentage increase in State and Federal prisons for women between 1995 and 2003 was 5.0 percent, compared to 3.3 per- cent for men. In 2003 more than 100,000 women were in State and Federal prisons, and women represented 11.1 percent of adults on parole under State and Federal jurisdiction in 1997 (Harrison and Beck 2004; Maguire and Pastore 2001).

About 60 percent of women in State prisons used drugs in the month prior to the offense for which they were convicted, and about half of these women admitted to daily drug use. Drug use at the time the crime was committed was higher for female inmates than for males (40 percent compared to 32 percent), but more male inmates than females were under the influence of alcohol at the time the crime was committed (Greenfeld and Snell 1999). Interviews with incarcerated women in California, Connecticut, and Florida State

prisons indicated that more than 80 percent had used substances regularly during their lifetimes while 71 percent reported regular substance use during the month prior to their most recent arrest (Acoca and Austin 1996). A study conducted by the Connecticut Department of Corrections indi- cated that 45 percent of female prisoners compared to 22 percent

95Adapting Offender Treatment for Specific Populations

Advice to the Counselor: Culture and the Counselor

•The most common misunderstandings in counseling origi- nate in culture, socioeconomic class, and language. It is the counselor’s job to be aware of and sensitive to the values, biases, and assumptions of his or her own culture and to provide culturally competent services to clients.

of male prisoners were in need of substance abuse treatment (Acoca 1998).

Many of the issues discussed in this section apply to male offenders as well as to females but are discussed here because the issues cre- ate greater problems for women offenders. (For more on women’s treatment issues in general, see the forthcoming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women [CSAT in development g].)

Compared to their male counterparts, female inmates are more likely to have mental disor- ders (Ditton 1999), to be HIV positive (Maruschak 2004), to have been physically or sexually abused (Harlow 1999), and to have lived with their children in the month prior to their arrest (Mumola 2000). According to Peters and colleagues’ (1997) study of women in a Tampa, Florida, jail treatment program, the most common mental disorders that incar- cerated women have are serious depression and anxiety disorders. In another study of women in jail awaiting trial, 60 percent were found to have substance abuse or depen- dence, 22 percent had posttraumatic stress disorder (PTSD), and nearly 14 percent had at least one major depressive episode in the 6 months before entering jail (Teplin et al. 1996). Varese and colleagues (1998) demon- strated that depression among female inmates is greater among women who have deficits in social skills (e.g., are less assertive and/or are more aggressive), have dysfunctional atti- tudes, and are less able to provide self-rein- forcement. These issues must be dealt with in substance abuse treatment programs for incarcerated women because they are inter- twined with substance abuse and criminal behavior (Henderson 1998).

Few substance abuse treatment programs have been developed specifically for female offenders, and many of the programs that do exist for women in jails and prisons are based on treatment models developed for male offenders (Peters et al. 1997). However, avail- able research suggests that treatment tailored for female offenders is effective. For example,

an outcome study of Forever Free from Drugs and Crime, a California program created specifically for women offenders, found that the longer an offender remained in Forever Free, the more likely she was to stay out of jail. Women participating in Forever Free come from California State prisons, live in a 240-bed housing unit, and receive treatment four hours per day, five days per week. Counseling addresses issues specific to women, such as dependency, physical and sex- ual abuse, and parenting. Information on Forever Free is available online at www.drugstrategies.org/ks1998/p_crimin.html or through the California Department of Corrections Office of Substance Abuse Programs at (916) 327-3707.

Women in treatment, particularly those in early recovery, need to feel they are in a safe environment, but many do not feel, and some are not, safe in jail or prison (Covington 1998). To try and make the treatment experi- ence feel safer, the harsh confrontational techniques often used in therapeutic commu- nities (TCs) can be modified for women’s pro- grams. Instead, a more supportive approach should be used, emphasizing therapeutic sanctions (e.g., participation in treatment activities) rather than punitive consequences (e.g., work assignments) for breaking rules. Nearly all women’s programs consider the use of harsh language, expressions of hostility, and physical force by staff members as detri- mental to their clients’ recovery (Welle et al. 1998). Indeed, such staff actions can recreate abusive interpersonal situations experienced by many of the female offenders while they were in the community. Also, rather than needing help in anger management, women are more likely to benefit from learning tech- niques to reduce “guilt and self-blame, improve self-esteem and self-awareness, and attempt to create an environment of safety and support” (Peugh and Belenko 1999, p. 31). Women are more likely to complete a treatment program designed specifically for women (Roberts and Nishimoto 1996), and clinical experience suggests that women are more likely to disclose personal trauma, such

96 Chapter 6

as sexual abuse and domestic violence, in sin- gle-sex groups.

Based on their research with women referred to a jail-based substance abuse treatment program, Peters and colleagues (1997) recom- mended that programs for female offenders adapt treatment approaches developed for clients with co-occurring disorders (COD). In part, this is because COD are so common in this population, but also because this is one area where more sensitive and flexible clinical approaches have been developed. They stress the need to be flexible in terms of the sequence, focus, and intensity of treatment and to adapt treatment to individual needs wherever possible. They also note that time needs to be set aside for the assessment and diagnosis of COD and for teaching a range of skills (i.e., parenting, nutrition and health care, accessing social services and housing) that are generally not considered as impor- tant in treatment programs for male offenders.

Further information on women’s treatment issues in general can be found in the forth- coming TIP Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development g), and more informa- tion about treatment for female offenders can be found in Technical Assistance Publication 23, Substance Abuse Treatment for Women Offenders: A Guide to Promising Practices (Kassebaum 1999).

Histories of Physical and Sexual Abuse Histories of abuse are of partic- ular concern for female offend- ers and can have a significant impact on treatment. (In the general population, about one third of women and between 3 and 24 percent of men have experienced physical or sexual abuse. Among substance using populations, the figures are higher [Gil-Rivas et al. 1997].)

The panel recommends that screening for a history of abuse be included as part of the intake assessments for women in criminal jus- tice treatment settings; to do this, a psychoso- cial history should be taken that asks about issues such as childhood abuse and domestic violence. One difficulty with addressing these issues with women who are incarcerated is that immediate ongoing counseling is not always possible, given that counseling staff may not be available every day. The consen- sus panel feels that programs should have aftercare available for clients with histories of abuse. These issues can take a long time to work through and, depending on the setting in which treatment is provided, sufficient time may not be available within the pro- gram. Treatment providers should be aware of the range of aftercare options available for clients who are leaving the facility to enter either the community or another facility.

Indepth treatment for the trauma related to a history of abuse should be provided by pro- fessionals specifically trained in this area. However, innovative strategies that help women address issues of abuse at a level with which they are comfortable have been devel- oped. For example, the Empowerment through Literacy Project helps women address issues of sexual abuse in a supportive group atmosphere. Women participate in a reading group that facilitates discussions on a number of important issues (e.g., sexual abuse, substance abuse) at the same time it promotes literacy. Readings pertinent to these women’s life experiences are selected, includ- ing books such as Maya Angelou’s I Know

97Adapting Offender Treatment for Specific Populations

Advice to the Counselor: Treating Female Offenders

• Nearly all women’s programs consider the use of harsh language, expressions of hostility, and physical force by staff as detrimental to client recovery as these actions recreate abusive interpersonal situations experienced by many of the female offenders while they were in the community.

Why the Caged Bird Sings, Janet Fitch’s White Oleander, and Elena Diaz Bjorkquist’s Suffer Smoke.

Under community supervision, an offender’s primary goal needs to be to remain drug free and out of trouble, and treatment programs may not have sufficient time or resources to treat all issues that impact their clients. In such cases, however, programs should be pre- pared to assist clients in finding a suitable treatment program where they can receive treatment for traumatic effects of abuse. Some providers conduct survivors’ groups that are geared toward including treatment for trauma issues within substance abuse treatment for women.

In addition to substances, women can also abuse children or even, occasionally, spouses. However, if a cycle of ongoing violence is going to be interrupted, the nature of a woman’s crime should not disqualify her for treatment. For example, a woman who is incarcerated for killing an abusive spouse will likely be considered a violent offender and therefore not qualify for treatment.

Two other TIPs are valuable sources of infor- mation about treating women with histories of child abuse (TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues [CSAT 2000d]) and who have been victims of domestic violence (TIP 25, Substance Abuse Treatment and Domestic Violence [CSAT 1997b]). The forthcoming TIP Substance Abuse and Trauma (CSAT in development f) also contains useful informa- tion.

Low Self-Esteem Low self-esteem certainly is not just a women’s issue. Many offenders, both male and female, experience low self-esteem. Guilt and shame over past actions are often con- tributing factors to a poor self-image and low self-esteem, but so is a history of discrimina- tion (whether toward the individual or the culture/ethnic group to which he or she belongs) that can produce poor self-esteem

when internalized. Low self-esteem often takes years to produce; it can begin early in life and be increased by physical and sexual abuse, substance abuse, and arrest and incar- ceration. In order to improve a client’s self- esteem, programs need to address this issue continually, affirming at each stage of treat- ment the client’s ability to change and create a positive life.

The strengths-based approach to treatment is widely considered the most effective approach for improving women’s self-esteem. The panel also recommends that group work be used with both women and men as a crucial means of building self-esteem. (TIP 41, Substance Abuse Treatment: Group Therapy [CSAT 2004], has extensive information on how to conduct a variety of substance abuse treat- ment groups.) Presenting positive role models to clients also is essential for women (even women who have not gone through the crimi- nal justice system can be role models).

For women, the more time spent in treatment the more likely self-esteem will increase; this increase is most likely if the women are in a residential/inpatient setting. A residential TC helps women build awareness of their strengths and helps them “practice” having higher self-esteem (De Leon and Jainchill 1981). However, if treatment is provided in an outpatient setting, women often return to unhealthy situations (e.g., domestic abuse, a job with low pay and high stress) after their treatment session and their self-esteem will drop again. It takes an extended period of positive reinforcement to raise a client’s self- esteem to a level sustainable in the face of oppressive forces. Of course, eventually clients will need to leave a treatment pro- gram, but to make that difficult transition as smooth as possible, programs should help the client connect to an appropriate support group.

Parenting and Child Custody The majority of women imprisoned in jails or prisons are parents and some programs in

98 Chapter 6

and out of prison are adding parenting work- shops to their agendas (see text box below). In 1999, more than 1.5 million children had a parent in prison (Mumola 2000; Petersilia 2000), and many more children have had a parent incarcerated during a period of their early lives. At least half of the children of imprisoned mothers have not seen or visited their mothers since incarceration began. Under the Adoption and Safe Families Act of 1997, parents of children in foster care for 15 or more of the past 22 months may have their parental rights terminated by the State. Given that the average prison term for incar- cerated women is 15 months (Genty 1998), an increasing number of parents are permanent- ly banned from their children’s lives—often a devastating blow for mothers and their children.

Parenting is not just a women’s issue, and, in fact, the vast majority (93 percent) of incar- cerated parents are male. However, mothers in State and Federal prisons are often (46 percent and 51 percent of the time, respec- tively) the sole parent living with their chil- dren at the time of their incarceration; 31 percent of mothers in prison were the only adult caring for their children before incar- ceration. Only 28 percent of the children of women in State prisons reside with their other parent and nearly 10 percent live in foster care or an agency. The majority of incarcer- ated mothers rely on grandparents or other members of their extended family to care for their children while they are incarcerated (Mumola 2000). If a woman is in prison and has no one else to care for her children, her loss of custody could be permanent.

Innovative community reintegration programs for female prisoners may feature eventual reunification with their children as a signifi- cant motivator for treatment.

Many incarcerated women feel enormous guilt about being away from their children and worry about maintaining custody of their children (Covington 1998). This guilt may be a motivating force, but it can also overwhelm the client and be a cause for relapse. In some cases, children are used to coerce a parent into treatment; family drug courts, for exam- ple, may remove children from a mother’s custody if she does not successfully complete treatment. However, the presence of children can be a mother’s only link to a stable life, and after losing her children to a Child Protective Services agency or another family member, she sometimes increases her sub- stance abuse.

Research does suggest that it is in the best interest of both mothers and their children to have continued interactions while the woman is incarcerated. Early research by Holt and Miller (1972) found that maintaining family ties and providing parenting training positive- ly affected a parent’s success on parole. Stevens and Patton (1998) have found that women in a modified TC that enables them to have their children with them had better treatment outcomes than women who had the same treatment unaccompanied by their chil- dren. The panel encourages jail and prison programs to allow for more interaction between incarcerated mothers and their chil- dren; the 2–4 hours of supervised visitation per week that many institutions allow is not

99Adapting Offender Treatment for Specific Populations

A Program for Paroled Women and Their Children

Walden House opened a residential treatment facility for paroled women and their children in El Monte, California, in 1999 as part of the Female Offender Treatment and Employment Programs (FOTEP). The program is based on the TC model but includes parenting skills, education and vocational preparation, job readiness, job placement, and intensive case management. FOTEP fosters an environment where clients learn new ways of meeting their needs without relying on substances. In addition to its emphasis on obtain- ing employment, the program includes components for children and models parenting behaviors (Smith 2001).

sufficient for mothers or their children. One program that is attempting to increase inter- actions between incarcerated mothers and their children is located at the Denver Women’s Correctional Facility (DWCF) and is described in the box above.

Job Skills Training As Peugh and Belenko (1999) note, female inmates with substance use disorders have poorer employment histories than their male counterparts, and likely have fewer opportu- nities for employment (especially at jobs that

pay more than minimum wage) than do men. Vocational training would reduce the need for women to turn to illegal sources of income to support themselves and their families after release (Peugh and Belenko 1999). Therefore, vocational training should be a priority for female offenders in substance abuse treat- ment; however, this often is not the case. The vocational options available for female inmates are often extremely limited compared to the options available for male offenders. Male offenders have more opportunities to learn higher-paying job skills (such as car- pentry or mechanics) than female offenders,

and so women too often return to jobs in the community that pay a low wage, do not enable them to support themselves and their children, and do not raise their self-esteem.

The panel recommends that in prisons and jails, substance abuse treatment programs and TCs introduce vocational pro- grams for women and expand

100 Chapter 6

The DWCF Program for Women and Their Children

DWCF opened in early 1999 to serve the needs of 900 female offenders. In addition to providing treatment for substance abuse and mental health problems, DWCF follows recommended treatment principles for incarcerated women by addressing gender-specific treatment issues such as improving the relationships of mothers and their children and increasing contact between them. All mothers in DWCF participate in a 12- week Parenting Skills Seminar as well as a 12-week seminar that focuses on family relationships (the Family Dynamics Seminar). Among other things, these seminars teach mothers about the importance of regular phone contact with their children to discuss things such as homework, report cards, and special school events. Additionally, the facility has placed special emphasis on increasing the frequency of phone contacts and visits between mothers and children. Visits are encouraged and facilitated by the DWCF staff. Special children’s visiting areas have been created; these are painted with motifs from children’s literature and fur- nished with colorful children’s furniture, games, books, and toys. The environment is attractive and appeal- ing to children and facilitates positive mother–child interactions. The DWCF administration also has estab- lished a collaborative relationship with a Quaker volunteer organization, whose members provide weekly transportation for children (and their caretakers) who lack other means of transportation to the facility. Additionally, the facility has developed several apartments within the prison, permitting weekend visits for mothers and their children during the 4 to 6 weeks prior to the mother’s release into the community; these visits help to reconnect mothers and their children during the crucial period just prior to discharge or parole. Staff monitor these visits and provide support and assistance for mothers and their children when needed.

Advice to the Counselor: Parent Training

• Discussions of parenting and the welfare of one’s chil- dren often promote strong emotional explorations and counseling opportunities.

• Offenders are sometimes more receptive to treatment and more willing to accept prosocial values when the appeal is made for the sake of their children.

the range of vocational skills taught. Programs for offenders under community supervision can obtain access to community vocational programs that will accept their clients. Because so many incarcerated women with substance use disorders have no real employment history or work skills, clients will benefit from learning prevocational skills, earning GEDs, and meeting other educational goals. Counselors can assess both women’s vocational interests and their existing work skills. One innovative program that is target- ing women with substance use disorders who are serving a prison sentence was developed by the Project for Homemakers in Arizona Seeking Employment (PHASE). A complete description of the program is available online at www.ag.arizona.edu/impacts/2000/ ready3.pdf.

TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000c), provides information on the impor- tance of vocational services, how to integrate them into substance abuse treatment pro- grams, and, in a chapter titled “Working With the Ex-Offender,” specific information on the vocational training needs of offenders.

Men’s Treatment Issues Because men make up the vast majority of offenders and because gender bias often makes people see men’s treatment as the norm, it sometimes is difficult to see how cer- tain issues need to be addressed for men in substance abuse treatment programs. Typically, these are issues that have been thought of as women’s issues (e.g., sexual abuse, parenting) but also can include issues that are significant for men in the general population, but often forgotten for offenders (e.g., status). Much of the information pre- sented above also applies to men. For more information on men’s issues related to sub- stance abuse treatment, see the forthcoming TIP Substance Abuse Treatment and Men’s Issues (CSAT in development e).

Fathering Male offenders often are very concerned about the welfare of their children, although socially defined gender roles still put more pressure on women to be good parents. Male offenders may not talk as much about their children or the feelings they have for them, but they often keep pictures of them and, if asked about them, express concern. According to Mumola (2000), 40 percent of fathers in State prison had at least weekly contact with their children.

It is particularly difficult for male offenders to admit that they failed as fathers. Being a good father is not, as some might expect, looked down on in prisons as a sign of “weak- ness,” but rather is generally perceived as an important and valuable activity. However, an individual perhaps feels a conflict between his role as a caring parent and the role of a “hardened criminal” that he presents within the prison.

Many male offenders feel inadequate when dealing with their children and have never had any instruction or assistance in how to be a good father. Their own fathers often were poor role models, and some were (and may still be) incarcerated themselves, even in the same prison. This does not mean, however, that they are bad fathers—just that they are not aware of what they should be doing or how well they are doing in that role. According to Landreth and Lobaugh (1998), at the end of a parent training class a group of incarcerated fathers was more accepting of their children, perceived fewer problems with their children, and had less stress about par- enting compared with offenders who did not participate. The children benefited as well from the structured play therapy, as their self-concept scores improved significantly.

Parent training can also serve as a bridge to counseling. Few criminal justice clients want their children to wind up in prison. Discussions of parenting and the welfare of one’s children often promote strong emotional explorations and counseling opportunities.

101Adapting Offender Treatment for Specific Populations

Offenders are sometimes more receptive to treatment, and more willing to accept pro- social values, when the appeal is made for the sake of their children.

Developing Relationships Learning how to relate to people and build relationships (including how to be a friend) takes a lot of work for men. In many cases, this is not a matter of rehabilitation but rather habilitation; some male offenders do not under- stand how to be a friend, family member, or significant other. They often experience great difficulty even talking about this issue, in spite of the fact that they want to learn these skills. One of the attractions of gang participation is that it gives members a sense of belonging and a certainty about their relationships with one another that they do not have outside the gang. Thus, treatment should encourage men to form relationships based on a shared experience with recovery. Relationship training also is important for job success. Learning how to communicate with peers and supervisors is nec- essary for maintaining employment and advancement.

Working With Violent Offenders While substance abuse treatment providers working in any setting may need to discuss vio- lence in a client’s past, this issue is especially important when working in the criminal justice system because offenders’ violence often has led to their arrest and conviction. Clinicians also must be aware of the possibility that vio- lence could erupt in the treatment program and should pay careful attention to issues that could trigger violence between offenders.

Relationship Between Substance Abuse and Violence Literature on the subject generally concludes that substance use often is a cause of or a predisposing factor for violence (Friedman

1998). Alcohol is the most frequently used substance that can precipitate violent crime. According to victim reports, perpetrators were clearly under the influence of alcohol in nearly 35 percent of violent crimes; two- thirds of victims who suffered violence caused by a current or former spouse or partner also reported that alcohol was a factor in the inci- dent (Greenfeld 1998). In a 1997 survey, 41.7 percent of State prison inmates and 24.5 per- cent of Federal inmates convicted of a violent crime reported that they were under the influence of alcohol at the time they commit- ted the crime for which they were convicted; 29 percent of State and 24.5 percent of Federal inmates reported that they were under the influence of drugs at the time (Mumola 1999).

There is some evidence that cocaine, amphetamines, and possibly other substances also have the potential to stimulate violent acts. The relationship of cocaine to violence is better established for those inner-city resi- dents who predominantly use crack cocaine (Friedman 1998). The possible effect of race, ethnicity, or culture on this relationship has not been studied systematically. Although more research is needed, there is at least some reason to believe that the relationship of drug and alcohol use to violence may be affected by cultural factors as well (Valdez et al. 1997). Earlier substance abuse seems to be associated with subsequent violent behavior for both women and men. The effect of alco- hol as a precipitant of violent crime is better established for men than women (Friedman 1998).

The relation between substance use and vio- lence is complicated, and there are many individual and group differences in the way substances are used and how they affect peo- ple. Some people may in fact use substances in order to be calmer and less prone to vio- lence; others may use them to forget the guilt associated with past acts of violence, which may then precipitate further acts of violence.

102 Chapter 6

Drugs influence levels of violence in other ways. The business of manufacturing and sell- ing drugs can be very violent, and offenders who have been involved in these activities may have committed violent acts in order to survive and succeed. A study demonstrating that legal prohibitions against the use of alco- hol or drugs actually increase the level of vio- lence (and homicide in particular) was pub- lished by Miron in 1999.

Managing Violence Within prison culture, violence is an every- day part of life and inmates may resort to vio- lence in order to protect themselves. The prevalence of violence in the system reduces a client’s feeling of safety within the treatment setting. Many offenders react with violence because they have never developed the social and coping skills necessary to react to prob- lems in more positive ways. This lack of skills is even more prevalent in offenders with extensive histories of substance abuse. Interpersonal violence is also associated with methamphetamine abuse (Cohen et al. 2003). The prison culture reinforces violent behav- ior. Individuals who are incarcerated without a history of violence quickly learn its value in jail or prison. Past violence is an issue partic- ularly for offenders who are making the tran- sition from incarceration to the community because past actions may come back to “haunt” them. It can be difficult to find treat- ment programs in the community that will accept violent offenders.

A number of programs have been developed to help offenders stop violent behaviors. Many of these programs use variations on cognitive–behavioral therapy (CBT) and ask offenders to look at their “criminal thinking” and the ways in which it leads them to commit violent crimes. Several programs have been developed from the model of the Oakland Men’s Project, a community-based violence prevention program for men that began in 1979. This project developed a series of work- shops that use role-playing exercises to help men understand how society pressures them

to commit (and rewards them for) violent actions.

Programs such as the Violence Interruption Process (VIP) of the Illinois TASC (Treatment Alternatives for Special Clients) and the Ohio Department of Alcohol and Drug Addiction Service’s (ODADAS) Ohio Violence Prevention Process (OVPP) were developed from the Oakland Men’s Project model. Illinois’s VIP works on the assumption that violent behavior is learned and has an institutional as well as a personal dimen- sion. When people become aware of how they have learned violent atti- tudes and behav- iors, they can learn new methods of communication and resolving conflicts (People for Peace 1996). ODADAS provides onsite trainings in OVPP to substance abuse treatment programs, corrections pro- grams, school sys- tems, and other groups; trainings touch on a variety of issues including the connection between substance abuse and violence, the role of racism and sexism in violence, and building multicultural alliances (ODADAS 2000). More information on promising vio- lence prevention and psychoeducational pro- grams in a range of locales can be found on the Partnership Against Violence Network (Pavnet) Web site (www.pavnet.org).

Anger management groups are another useful intervention with this population but the con- sensus panel recommends that these groups be connected with other interventions and not simply provided as a stand-alone treatment for violent offenders. A variety of curricula are available for running anger management

103Adapting Offender Treatment for Specific Populations

Treatment should

encourage men to

form relationships

based on a shared

experience with

recovery.

groups in jail or community settings. Incentives also are very important when deal- ing with this population. These are clients who have not had much positive reinforce- ment in their lives and have grown accus- tomed to reacting to negative reinforcement with anger and resentment. Head trauma and related brain injury can be another cause of

violent behavior (Diaz 1995; Robinson and Kelley 2000).

In some cases, med- ication may be called for in order to manage aggres- sive behaviors (Lavine 1997). When medical, psy- chiatric, and sub- stance abuse assess- ments indicate that a client’s aggressive- ness is not under control, pharmaco- logical treatment sometimes is consid- ered.

Treatment Issues Based on Client’s Sexual Orientation Sexual orientation and sexual behavior are not necessarily congruent, especially within a prison or jail. Many offenders who engage in homosexual activity while in jail or prison do not self-identify as gay, lesbian, or bisexual. Others, who may recognize that they are gay, lesbian, or bisexual, do not openly proclaim that fact (i.e., are not “out”) in an incarcerat- ed setting because they fear reprisals. The institutional culture of men’s jails and prisons may recognize only the “passive” or receiving sexual partner as gay, which supports a het- erosexual self-identification for some men who engage in homosexual activity.

Incarcerated individuals may engage in sexual activity with members of the same gender for many reasons, not all of which reflect their sexual identity. Self-identified heterosexuals may engage in prostitution for money or have sex in order to gain the protection they need to survive within the jail or prison. For such individuals, sexual identity can become an especially important issue upon release as they try to understand their sexual activity and how it relates to their identity and sexual identification. There may be, in fact, men within the prison system who have had more sex with men than women but who still identi- fy as heterosexual. These individuals may face particular difficulties when they return to sex with female partners and may use sub- stances in order to facilitate heterosexual activity.

Reliable data on the prevalence of homosexu- al behavior in jails and prisons are limited. In one study of a low-medium-security prison, which claimed to underreport some types of sexual behavior, 55 percent of self-identified heterosexuals reported being involved in sex- ual activity in prison (Donaldson 1990). Despite disciplinary codes in jails and prisons that prohibit all sexual activity, such behav- ior still occurs. Within men’s prisons there is a social hierarchy based on sexual roles. Although middle-aged and older men are most likely to abstain from sexual activity while incarcerated, others engage in sexual behav- iors to assert their masculinity, to establish power over others and over their own lives, and, in the case of stable relationships, to provide companionship. Relationships between inmates imply obligations by each partner: the dominant partner to defend his partner physically against mistreatment by others and the receptive partner to obey the other (Donaldson 1990).

In a study of homosexual behavior in prison, Alarid (2000) surveyed men incarcerated in a county jail who had requested and received protective custody because of their sexual ori- entation. The gay and bisexual men in the group tended to be older and never married.

104 Chapter 6

People with

substance use

disorders may

experience a

coexisting cogni-

tive or physical

disability.

Nearly half were African American. Slightly more than half of the men in this study self- identified as bisexual, with one third of those preferring female partners (bisexual/hetero- sexual). Gay and bisexual men were generally satisfied with their sexual orientation. Almost one fourth of the group (a majority of them gay) exchanged sex for money or favors. The bisexual/heterosexual group felt more pres- sure to have sex and often used it to gain the protection of another inmate. This is perhaps a result of the fact that the group was small in number and that other inmates sought them as sexual partners. Most of the group believed that their fellow jail inmates treated them dis- respectfully. Only a few gay inmates and none of the bisexuals felt that jail personnel toler- ated gay behavior or gay or bisexual individu- als. More than a third of this group feared being raped in prison and believed that hav- ing the protection of a heterosexual was the best way to do prison time (Alarid 2000).

In male institutions, individuals who do self- identify as gay are often victims of rape and/or physical violence. They may need to resort to violence to protect themselves or else become a sexual partner of someone who can protect them. However, these are not typical- ly mutual relationships and the gay partner often needs to assume a submissive role that may not be compatible with the sexual role he prefers; gay inmates often wish to distance themselves from these partners upon release.

Many women also face conflicts between sexu- al orientation and sexual behavior when incarcerated. However, generally, confusion around sexual orientation is not as difficult for women because sexual encounters in prison involve more of a relationship than they do for men; sexual activity is often a part of a nurturing, family relationship (and women often explicitly take on roles as “hus- bands and wives”). It is assumed that the prevalence of homosexual activity in women’s jails and prisons is similar to that in men’s. In contrast to relationships among men, women establish partnerships voluntarily and con-

sensually. These partnerships are generally respected by other inmates (Donaldson 1990).

Female offenders also seem more accepting of openly lesbian women than their male coun- terparts are of openly gay men. Overall, les- bian women have an easier time dealing open- ly with sexuality while incarcerated than gay men. They may develop very close relation- ships with other women while incarcerated and express regret that the relationship may end after one partner leaves the institution. Some lesbian offenders say that they enjoy the sexual freedom that a prison environment allows them, and, after release, may express a desire to return to a relationship they had while incarcerated.

Other issues related to sexual orientation, such as conflicts with the family of origin and societal discrimination, can create additional stress that can lead to increased substance abuse. For more general information on working with this population, see A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001).

Treatment Issues Based on the Client’s Cognitive/Learning, Physical, and Sensory Disabilities People with substance use disorders may experience a coexisting cognitive or physical disability. A study by the New York State Office of Alcoholism and Substance Abuse Services found that more than 22 percent of the clients served by licensed treatment facili- ties had a co-occurring mental or physical disability (CSAT 1998d). Self-reports from inmates in 1997 indicate that 31 percent of State prisoners and 23 percent of Federal prisoners had learning or speech disabilities, hearing or vision problems, or mental or physical conditions. This includes 108,000 individuals with learning disabilities, 135,000

105Adapting Offender Treatment for Specific Populations

with physical impairments, 65,000 with hear- ing problems, and 94,000 with vision prob- lems (Maruschak and Beck 2001).

Evidence suggests that people with cognitive disabilities are disproportionately involved in the criminal justice system (Cockram et al. 1998). Nearly one third of inmates in State prisons and one quarter of those in Federal prisons report having a physical or cognitive disability. These data, derived from self- reports, are likely to underrepresent some conditions, including learning disabilities, of which inmates themselves may not be aware. Ten percent of State and 5 percent of Federal prison inmates report a learning disability. Also, data from inmates in State prisons show that they are three times more likely than the general population to have a speech disability and more than twice as likely to have impaired vision. These inmates are, however, slightly less likely to have a hearing impair- ment, but this can be accounted for by the age and gender differences from the general population (Maruschak and Beck 2001).

People with cognitive disabilities are at a sig- nificant disadvantage in their contacts with the criminal justice system. For example, offenders with developmental challenges are disproportionately likely to be arrested and coerced into a confession for a crime they did not commit. They may not understand their Miranda rights and are eager to please, igno- rant of the value of remaining silent, suscepti- ble to leading questions, insensitive to non- verbal cues, and desirous of appearing com- petent (Cockram et al. 1998). They also are easily led into criminal activity by others, and, in their desire to feel like they belong to a group, they may even view arrest and incar- ceration as successful achievements (Wood and White 1992). Inside jails and prisons, they tend to be victimized by other inmates, and often try to hide the presence of their dis- ability in order to avoid further victimization. According to focus group interviews with fam- ily members of people with cognitive disabili- ties, one way the criminal justice system could better assist people with cognitive disabilities

is to provide qualified staff members to work with them in the early stages of the legal pro- cess (Cockram et al. 1998).

Jails and prisons can be difficult places for people with physical disabilities (e.g., there may be no wheelchair access and bathrooms may not be fitted with hand rails). Sometimes clients with disabilities can be moved to other facilities that are not necessarily appropriate for them, given their sentence (e.g., they may be moved to a medium security facility even though their sentence warrants maximum security). In June 1998, the U.S. Supreme Court ruled that State prisons must comply with the provisions of the Americans with Disabilities Act. This means that they must make reasonable accommodations to provide access to basic facilities and services for eligi- ble prisoners with disabilities (American Civil Liberties Union 1998).

Certain physical disabilities require medica- tion, and this can pose particular problems for treatment facilities in jails and prisons. Facilities may need to give offenders medica- tions at specific times that could conflict with other scheduled activities. Clients under com- munity supervision require a support system that can help them manage their medication and oversee compliance.

Clients who have conditions such as diabetes that require the administration of medication by means of a syringe may face daily what could be a significant trigger for substance use. In the community, they will have to con- tend with the theft or use of their syringes by others. These clients will need assistance in looking at these triggers and developing a relapse prevention plan that addresses them. For example, individuals who need to admin- ister medications using a syringe who are no longer in a residential program could have a friend or relative available to be with them when they give themselves their shots (at least for the first few months after release). Programs can provide these individuals with a small safe where they can keep needles and should advise them to keep syringes in more

106 Chapter 6

than one place so that if any are stolen they will still be able to administer their medica- tion. Individuals should always check their syringes to see if others have used them and should keep a supply of bleach available to clean needles if they suspect their needles have been used.

Given the prevalence of disabilities in incar- cerated populations, especially among offend- ers with substance use disorders, the consen- sus panel suggests that treatment providers be able to screen for co-existing disabilities and make accommodations for offenders who have them. For example, someone with mental retardation may not be able to participate in a traditional TC and may need to be sent to a modified TC or have another suitable treat- ment option available. Information on treat- ment for clients with co-existing disabilities can be found in TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT 1998d).

Treatment Issues for Older Adults Age is a factor associated with positive treat- ment outcomes. The older one is the more likely one is to stay in treatment, complete treatment, and have positive outcomes follow- ing treatment. For some older clients the neg- ative consequences of a criminal lifestyle accumulate over time, while the body becomes less capable of managing substance abuse and related stressors, leading to a desire for change. Engaging these individuals in treatment may be relatively easy. However, older offenders also have unique issues that counselors need to be prepared to address. For one, this population is more prone to health problems. Visual impairments and hearing loss are factors, along with chronic health problems, senile dementia, and demen- tia related to long-term substance abuse. Other characteristics typical of this popula- tion that complicate treatment include

• A slow response to directions

• Rigid habits

• The likelihood of a physical condition pre- senting as an emotional problem

• Lifelong patterns of criminal behavior that cannot easily be altered

• A lack of assertiveness, suggesting that younger, more verbal inmates are more likely to get treatment (Chaiklin 1998)

Readers are referred to TIP 26, Substance Abuse Among Older Adults (CSAT 1998c), for more information on sub- stance abuse treat- ment for this popu- lation. See also chapter 9, Issues Specific to Treatment in Prisons, for a description of how older inmates can serve an important function in prison- based substance abuse programs.

Treatment Issues for Clients From Rural Areas In the past, alcohol has been the largest sub- stance abuse problem in rural areas, but that is beginning to change. While certain sub- stances of abuse are more available than oth- ers, illicit substances are reaching rural com- munities. There is now no difference in prevalence of illicit drug use between large and small metropolitan areas and rural areas with the exception of marijuana (National Center on Addiction and Substance Abuse [CASA] 2000). In an evaluation of substance abuse in rural Nebraska, marijuana was found to be the most common drug (as it was in urban areas), but methamphetamine abuse was more common than cocaine abuse; those

107Adapting Offender Treatment for Specific Populations

Age is a factor

associated with

positive treatment

outcomes.

who abused substances tended to be younger than those in urban Nebraska and were more likely to be involved in the selling of drugs (Herz 2000). However, these patterns vary by region; for example, in rural northern Louisiana, cocaine abuse predominates and methamphetamine abuse does not seem to be a significant problem (Monroe 1998). Abuse of OxyContin has been more common in sev- eral rural areas, such as the eastern Kentucky and western Virginia areas of Appalachia.

Clients from rural communities have distinct cultures that differ from region to region. Treatment staff working with clients from a particular rural population should seek to understand that culture in the same way they would any other. Increasingly, offenders from urban areas are being sent to prisons located in rural regions and staffed by local resi- dents; here again, a cultural clash can devel- op, and training can help staff understand the cultural background of offenders coming from urban areas.

Services available in rural areas may also be more limited than those in more densely pop- ulated regions. A rural jail, for example, is generally unable to develop a substance abuse treatment program because its resources are limited. Community supervision programs in rural areas also have particular difficulties. Few programs will be available, there is little coordination between programs, privacy and confidentiality may be difficult to maintain, and certain types of substance abuse (e.g., excessive alcohol consumption) may be the norm in the area.

Treatment Issues for People With Co- Occurring Substance Use and Mental Disorders According to a study conducted in 1998, an estimated 283,800 offenders in jails and prison and another 547,800 on probation reported having a mental disorder and/or had stayed overnight in a mental hospital (Ditton 1999). Reported mental disorder varied across setting, with 16.2 percent of inmates in State prison, more than 7 percent of Federal prison inmates, 16 percent of jail inmates, and 16 percent of probationers reporting mental disorders or a stay in a mental hospi- tal. Rates were substantially higher for women than men and for Caucasians than African Americans or Hispanics/Latinos. Individuals with mental disorders were more likely to have been under the influence of substances at the time of their offense and substantially more likely to report a history of substance abuse than others (Ditton 1999). The National GAINS Center, a Substance Abuse and Mental Health Services Administration (SAMHSA) initiative to study mental health and substance abuse services for people in the criminal justice system, esti- mates that of jail inmates identified with men- tal illness, 64.3 percent reported alcohol or drug use at the time of the offense. Among the State prison population the figure is 58.7 per- cent (National GAINS Center 1997).

Even conservative estimates report high rates of mental disorders. Ditton (1999) reports that three previ- ous studies of inmates in jail or State prison with rigorous sam- pling methods found rates of mental disorders to be between 8 and 16 percent. A study of incarcerated women awaiting trial in a Chicago jail found sig- nificantly higher rates of mental disorders based on offender

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Advice to the Counselor: Rural Clients, Rural Counselors

• Clients from rural communities have distinct cultures that differ from region to region. In addition, more and more offenders from urban areas are being sent to prisons in rural regions with local staff.

• Counselors should seek to understand urban–rural differ- ences in culture as they would any other.

reports of psychiatric symptoms; 18.5 percent of the women had experienced symptoms of a severe disorder (i.e., schizophrenia/ schizophreniform, manic episode, major depressive episode) at some point during their lives, 33.5 percent had experienced PTSD, and 70.2 percent had a substance use disor- der (Teplin et al. 1996).

More information on the treatment of clients with COD can be found in TIP 42, Substance Abuse Treatment for Persons With Co- Occurring Disorders (CSAT 2005c).

Identifying Co-Occurring Disorders There is a great deal of stigma associated with mental disorders even within the culture of prisons and jails. At the same time, in correc- tional institutions, substance abuse does not carry the same degree of stigma as it does in the outside community. In some prison set- tings, procedures such as public medication lines expose the inmate with a mental disor- der to public ridicule, adding to the stigma and reinforcing the inmate’s reluctance to admit to his or her disorder. Offenders may be willing and able to face talking about their criminal activity or substance abuse but reluctant to discuss their mental disorder. Consequently, actual rates of mental disor- ders in this population are likely to be higher than self-reported rates.

Because one disorder can mask or imitate the other, accurate diagnosis of COD requires skilled screening and assessment. Assessment should look for both problems at the same time, rather than separating assessments for mental disorders and substance abuse. Regular reassessment is also important. Trained staff should be used to perform such assessments. Most prison programs for inmates with COD do use doctoral-level staff for initial screenings (Edens et al. 1997). For more on screening and assessing for COD, see chapter 2.

Co-Occurring Disorders Treatment Programs In order to serve the high number of offenders with mental and substance use disorders, a number of diversionary and corrections-based programs have been developed for offenders with COD.

Diversionary programs for offenders with co-occurring disorders These programs, generally referred to as Mental Health Courts, currently exist in a handful of municipalities across the country (Broner et al. 2002). SAMHSA has funded jail diversion programs at nine sites for offenders with COD. In the Eugene, Oregon, program, for example, mental health and substance abuse treatment is collaborative; sanctions applied are sensitive to mental health problems and the case manager is a mental health specialist who acts as court liai- son (National GAINS Center 1999b).

Prison- and jail-based pro- grams for offenders with co- occurring disorders In addition to diversion programs such as mental health courts, there has been a rapid growth in corrections-based co-occurring pro- grams during recent years, from only 2 State systems that had developed these programs in 1993, to 7 systems with programs in 1997, to 18 systems in 2002 (Edens et al. 1997). However, few State systems have systematic procedures for identifying and tracking prison inmates with COD. Moreover, little research has yet been done on the effective- ness of these programs. Preliminary outcome data from one study comparing a modified therapeutic community (MTC) program for prison inmates with COD with treatment as usual and with a mental health group showed the MTC group to have fewer new arrests,

109Adapting Offender Treatment for Specific Populations

less use of illicit drugs, and better compliance with treatment regimens (Sacks et al. 2001).

Several features distinguish the programs that treat inmates with COD from other criminal justice substance abuse treatment programs:

• An integrated treatment approach is used whenever possible. Mental health treatment staff, substance abuse treatment staff, and criminal justice staff are located in the same program unit, and often share in decision- making. In some jurisdictions, both correc- tional officers and community supervision officers have been successfully involved in treatment team meetings, treatment groups, and other therapeutic activities. A wide range of treatment approaches are imple- mented, according to the client’s stage of treatment. Collaboration and/or consulta- tion may be adequate to serve offenders who have less severe COD.

• Both disorders are treated as “primary.” Integrated treatment involves simultaneous consideration of both disorders and atten- tion to the interactive nature of these disor- ders. However, the scope and intensity of treatment activities will vary according to the client’s needs and functioning level.

• Comprehensive treatment services are flexi- ble and individualized. Treatment should be adapted to address different levels of symptom severity, functioning, and commit- ment to treatment. Both early intervention and active treatment interventions should be adapted for different diagnostic groups and for offenders with special needs (e.g., those with cognitive impairment, women with trauma and abuse histories).

• Treatment approaches that are commonly used in substance abuse treatment settings (e.g., TCs, cognitive–behavioral treatments, relapse prevention, peer and alumni sup- port groups) are adapted to better suit the needs of offenders with COD. Common modifications include smaller caseloads, shorter and simplified meetings, special attention to criminal thinking, education about medication, and minimizing con-

frontation (Edens et al. 1997; Peters and Hills 1997).

• Treatment is provided in graduated “phas- es” or “stages,” using a highly structured psychoeducational treatment approach. Early phases of treatment include a focus on orientation, assessment, development of treatment plans, and engagement and per- suasion activities. Didactic approaches are particularly useful in early stages of treat- ment to help offenders understand the nature of their mental disorders and biolog- ical aspects of both disorders. Secondary phases focus more on “active treatment,” such as development of coping and life skills, lifestyle change, and cognitive– behavioral interventions. Later phases may include relapse prevention, peer mentor activities, vocational training, reentry plan- ning, and linkage with community support and treatment programs. Case management and relapse prevention activities often are provided throughout the various phases of treatment, with a particular emphasis dur- ing prerelease and reentry phases. In jails, where the relatively brief period of incar- ceration may prevent the use of a long-term phased treatment approach, services may focus on assessment, brief psychoeducation- al interventions, community “in-reach” ser- vices, and linkage to community services.

• The focus of treatment is long term, with an emphasis placed on continuity of treatment in aftercare and postrelease settings. Recovery and stabilization for offenders with COD often occurs over a period of sev- eral years and includes multiple treatment episodes. COD treatment programs should provide linkage with other community treatment and ancillary service providers, and should develop detailed aftercare, tran- sition, and postrelease plans to ensure con- tinuity of services. These should include provisions to furnish an adequate supply of psychotropic medications for the offender during transition from institutional to com- munity programs. The offender also should be monitored carefully during transition periods, when stress levels are high and

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there is increased risk for recurrence of mental health symptoms, substance abuse relapse, and recidivism. Forensic coordina- tors or other case managers have been used successfully in some jurisdictions to help in community transition.

• Staff are trained and experienced in treat- ing both mental disorders and substance abuse. A blend of staff experience is need- ed, including those trained in working with acute symptoms of mental disorders and those who have worked in specialized sub- stance abuse treatment settings, such as TCs. Cross-training activities are useful to share information from the perspectives of each of the treatment disciplines, and also from the perspective of security/community supervision.

Programs for offenders with co-occurring disorders under community supervision This group of offenders will have particular difficulties finding aftercare programs to accept them because of the stigma associated with the combined problems of COD and a criminal record. Nor will most traditional community mental health interventions be effective for them, as they typically have com- plex problems that require specialized treat- ment (Broner et al. 2002). Community super- vision of offenders with COD also requires specialized strategies (Peters and Hills 1997), including

• Recognition of special service needs

• Use of supportive rather than confrontation- al approaches

• Positive reinforcement for small successes and progress

• Different expectations regard- ing response to supervision

• Flexible responses to infrac- tions

• Use of concrete directions

• Highly structured activities

• Ongoing monitoring

• Enlistment of support from family members to work with offenders with COD where appropriate

• Close coordination between the community supervision/probation officer and the offend- er’s clinician

Medication Management Substance abuse treatment providers working with people with COD need to understand and be able to help educate clients about the importance of medication management and compliance. Clients sometimes have trouble distinguishing between “good” and “bad” drugs, particularly at the beginning of treat- ment. The distinction is made more difficult by the fact that the “good” medications are more expensive and more difficult to obtain than illicit drugs. There still is a myth within the substance abuse treatment field that use of psychotropic medication by individuals with co-occurring mental disorders should be discouraged. Programs in criminal justice set- tings should update their formulary so that they are using the most up-to-date medica- tions. Offenders entering jails may have par- ticular problems around medications because they may not be able to receive necessary medication while incarcerated or may not be given a supply of medication upon discharge (which they might need until they can get pre- scriptions filled). It often takes well over a month to be seen by a psychiatrist and to receive a prescription for medication. In addition, certain medications (e.g., anti- depressants) take several weeks to build up to effective levels in the bloodstream. Moreover,

111Adapting Offender Treatment for Specific Populations

Advice to the Counselor: “Good” and “Bad” Drugs

• Clients with COD need help with medication manage- ment, especially in distinguishing between substances of abuse and licit medication.

• Counselors must be alert to inmates who skillfully mimic the symptoms of mental disorders in order to receive medications.

individuals often do not have enough money to pay for the medication. The consensus panel suggests that programs working with people who are making a transition from institution to community need to ensure that these clients have an adequate supply of psy- chotropic medications.

On the other hand some inmates can skillfully manipulate signs and symptoms of mental dis- orders in order to receive medications with sedative properties. Some of these medica- tions (such as benzodiazepines, prior-genera- tion antidepressants, and antipsychotics) can have serious and severe side effects. These medications can be sold to other inmates or exchanged for favors.

Case Management Services Case management services are useful in pro- viding access to a broad range of mental health and substance abuse services and are complementary to a range of other treatment approaches used with offenders with COD. Research indicates that case management ser- vices can lead to improvement in a client’s functional status and fewer hospitalizations during an extended followup period (Mueser et al. 1997). One model is Intensive Case Management (ICM). ICM is provided by mul- tidisciplinary teams that include mental health treatment staff, substance abuse spe- cialists, housing specialists, and community supervision officers. These teams often share caseloads to provide flexibility in coverage. Participation in treatment is provided through crisis and outreach services, use of specialized engagement and motivational strategies, and culturally relevant program- ming over an extended period of time.

Services provided by case managers are developed to address the stage of COD treat- ment (Lurigio 2000b). This includes an early emphasis on client engagement and commit- ment to the recovery process, and is followed by persuasion to consider abstinence and to begin active behavior change. Later stages of treatment include the use of cognitive–behav-

ioral interventions, development of a drug- free social support network, understanding of relapse risks, and use of relapse prevention skills. Another frequently employed case management approach for use with COD is the Assertive Community Treatment model (ACT) (Brown 2003; Stein and Test 1980). Key elements of this approach include crisis intervention, supportive therapy, substance abuse counseling, skills training, medication monitoring, housing support, vocational reha- bilitation, specialized dual diagnosis groups, family psychoeducational groups, and family outreach activities.

Special Considerations in Treating Antisocial Personality Disorder (ASPD) Substance abuse often is associated with crim- inal or antisocial lifestyle and is highly corre- lated with ASPD (Knop et al. 1998; Robins and Regier 1991). Someone with ASPD does not accept society’s values or norms and acts without guilt; he sees other people as objects to meet his needs. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), ASPD “is a pattern of disregard for, and violation of, the rights of others” (American Psychiatric Association [APA] 1994, p. 645). In order to be diagnosed with ASPD, a person needs to demonstrate, after the age of 15, three or more of the asso- ciated traits. (See Figure 6-1 for list of traits.) Given these criteria it is easy to see why offenders who abuse substances often are diagnosed with ASPD. In a sample of 325 psy- chiatric patients who had recently been hospi- talized, Mueser and colleagues (2000) found that both a history of incarceration and ASPD were predictive of substance use disor- ders. In another study that looked at clients in substance abuse treatment, Compton and colleagues (2000) found that 44 percent quali- fied for ASPD at some time during their life. Research from a male prison TC found 52 percent of clients had ASPD (Wexler and Graham 1993).

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While it is generally believed that ASPD is more common in men than women, available data are mixed. Researchers studying people in psychiatric hospitals (Grilo et al. 1996), in treatment programs for alcoholism (Cornelius et al. 1995), and in homeless populations (North et al. 2004) have found significantly higher rates of ASPD for men than for women. Galen and colleagues (2000), howev- er, found prevalence rates of 16 percent for men and 22 percent for women in a group of 235 clients at outpatient substance abuse treatment centers. Rates are high for offend- ers of both genders. A study of women enter- ing prison in North Carolina found that rates of ASPD were significantly higher than for women in the general population (Jordan et al. 1996), and Teplin and colleagues (1996) in their study of women in Cook County, Illinois, jails found that 13.7 percent met DSM-III-R criteria for ASPD within the 6 months prior to their incarceration.

The panel cautions that some people who meet the criteria for ASPD do not really have the disorder—their behaviors are the result of other factors, most notably substance abuse. The behavior of these clients is improved greatly after treatment. It is not easy, though, to determine who really does have ASPD and who does not. There also are

people who have ASPD but who lie about behaviors that qualify for this diagnosis.

Psychopathy is a term used to describe a more extreme form of ASPD. In addition to the criminal tendencies apparent in ASPD, people with psychopathy also exhibit affective and interpersonal dysfunction (Hare et al. 1991). Moreover, offenders who score high on the PLC-R (the test for psychopathy; see chapter 2 for more information) have higher rates of recidivism and are more prone to vio- lence both in and out of criminal institutions (Hare et al. 1991).

ASPD and psychopathy are difficult to treat and in this regard are addressed somewhat differently from other mental disorders. Approaches used for offenders with ASPD and psychopathy are typically focused on behavior management rather than on counsel- ing or other therapeutic techniques. These approaches involve heightened accountability (i.e., surveillance and monitoring), highly structured programming, and application of carefully crafted sanctions and incentives for targeted behaviors.

People with severe ASPD require intensive, long-term residential treatment for their dis- order and for substance abuse; if they inter- rupt treatment they are likely to return to

113Adapting Offender Treatment for Specific Populations

Figure 6-1 Traits of ASPD (DSM-IV)

• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

• Irritability and aggressiveness, as indicated by repeated physical fights and assaults

• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

• Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

• Impulsivity or failure to plan ahead

• Reckless disregard for safety of self or others

• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

Source: Hare et al. 1991.

previous behaviors. It should be noted, how- ever, that about half of all people with ASPD display fewer antisocial behaviors as they grow older, beginning in their 40s or 50s (APA 1994). More information on the treat- ment of clients with COD can be found in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c).

Special Considerations in Treating Borderline Personality Disorder (BPD) According to the DSM-IV, borderline person- ality disorder is characterized by “a perva- sive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adult- hood and present in a variety of contexts” (APA 1994, p. 654). It can include recurrent suicidal or self-harming behavior, intense anger or inability to control anger, and stress- related, psychotic-like symptoms (see Figure 6-2, below). Women are three times more likely than men to be diagnosed as having BPD (APA 1994).

Treating offenders with BPD requires great care due to their emotional instability, ten- dency toward violence, and risk for self- destructive or suicidal behavior. Moreover, because of their tendency to idealize coun- selors, the therapeutic relationship is likely to be intense, and the offender with BPD is like- ly to have strong reactions to the counselor. The American Psychiatric Association recom- mends that treatment for people with BPD take into account these special features:

• Co-occurring disorders. In addition to sub- stance use disorders, mood disorders, eat- ing disorders (especially bulimia), PTSD, anxiety disorders, dissociative identity dis- order, and attention deficit/hyperactivity disorder are especially common in people with BPD.

• Use of alcohol and illicit substances. People with BPD rarely are forthcoming about their use of alcohol and illicit substances. Counselors should inquire specifically about substance use from the beginning, and continue to educate clients about the dangers of substance use.

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Figure 6-2 Borderline Personality Disorder

People diagnosed with BPD must have five or more of the following behaviors:

• Frantic efforts to avoid real or imagined abandonment

• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

• Identity disturbance or markedly and persistently unstable self-image or sense of self

• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)

• Recurrent suicidal behavior or gestures, or self-mutilating behavior

• Affective instability due to marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxi- ety usually lasting a few hours and only rarely more than a few days)

• Chronic feelings of emptiness

• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

• Transient, stress-related paranoid ideation or severe dissociative symptoms

Source: APA 2000.

• Violent behavior and antisocial traits. Treatment courses will vary according to the degree of violent or antisocial behavior. In mild cases (e.g., shoplifting), cognitive therapy is recommended. For more severe cases, residential treatment (e.g., a TC) may be effective. Episodic violence may benefit from the use of mood-stabilizing medication. For severe antisocial features, hospitalization may be required.

• Self-destructive behavior. Addressing self- destructive behavior is a primary part of treating BPD. Behaviors such as self-muti- lation, suicide attempts, risky sexual behav- ior, and reckless driving are immediate threats to the individual and should be given treatment priority. Helping clients to think through the consequences of destruc- tive behavior can be of use.

• Childhood trauma and PTSD. While not universal, childhood trauma is very com- mon among people with BPD. Treating offenders with BPD will often entail addressing the trauma and symptoms of PTSD.

• Dissociative symptoms. Because there often is comorbidity between BPD and dissocia- tive disorders, counselors must also be aware of the likelihood that the offender with BPD experiences transient dissociative symptoms (e.g., depersonalization, dereal- ization, and loss of reality testing), and/or dissociative identity disorder. Counselors can assist by exploring the extent of the dis- sociative symptoms, the current issues that may lead to dissociative episodes, and the nature of dissociative symptoms. It may also be helpful to teach clients how to con- trol dissociation and to work through post- traumatic symptoms.

• Psychosocial stressors. Stress can heighten the symptoms of BPD, trigger relapse, and undermine recovery. Moreover, because of their intense fear of abandonment, many clients with BPD will be sensitive to any perceived rejection within any relationship, including the client–counselor relationship. Counselors should thus be watchful of reac-

tive behavior that often results when the offender feels in danger of being aban- doned. (For more information, go to www.psych.org/psych_pract/treatg/pg/ borderline_revisebook_index.cfm.)

A general clinical observation is that the TC is an effective treatment for both ASPD and BPD through the emphasis on interventions that facilitate socialization and maturity.

Special Considerations in Treating Depressive and Bipolar Disorders Treatment strategies for offenders with co- occurring major depressive disorders have focused on modifying thoughts that lead to depression or that are related to substance abuse. Issues surrounding loss and trauma are typically addressed when an offender is able to tolerate uncomfortable mood states without turning to substance abuse. Activities are designed to promote understanding of how trauma and abuse experiences are expressed through emotions, physical reac- tions, and behaviors, including substance abuse. In addition to the interventions for depressive disorders, treatment for offenders with bipolar disorders addresses impaired judgment that occurs during manic episodes, and the effects of substance abuse on judg- ment. Treatment strategies often focus on building an acceptable set of coping responses to manic or hypomanic impulses, as well as medication adherence when warranted.

Special Considerations in Treating Schizophrenia/ Psychotic Disorders Treatment for offenders with co-occurring psychotic disorders is designed to address dis- organized thought patterns and communica- tion style. Specialized approaches used in treatment include use of concrete concepts, avoiding harsh confrontation, and greater use of structured exercises and written materials.

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Offenders who have psychotic disorders often abuse substances for many of the same rea- sons as other individuals. Key treatment com- ponents include education in drug refusal skills, identification of strategies to fight bore- dom, building supportive social networks, and medication adherence.

Special Considerations in Treating Attention Deficit/ Hyperactivity and Other Cognitive Disorders Interventions for offenders with co-occurring attention deficit/hyperactivity disorder (AD/HD) focus on interpersonal difficulties, social skill deficits, and cognitive skill-build- ing to address impulsiveness and aggression. Information should be conveyed visually as well as orally when possible. Short therapeu- tic sessions provided in environments that have few distractions are preferable. With this population it is particularly important to repeat important themes and to rehearse key skills in various settings. Those with cognitive disorders need concrete, practical informa- tion and skills. (See also TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities [CSAT 1998d].)

Special Considerations in Treating PTSD, Phobias, and Other Anxiety Disorders Treatment of co-occurring anxiety disorders focuses on interventions to improve social skills and to modify cognitions associated with difficult interpersonal situations, particularly those that augment anxiety. It is particularly important in treating clients with anxiety dis- orders for the counselor to be calm and reas- suring. Clients with PTSD often make slow progress in achieving the trust necessary in a therapeutic alliance. It is important not to encourage discussion of traumatic events, particularly early in treatment. Those whose trauma-related symptoms are severe can ben-

efit from learning techniques to help them focus on staying in the “here-and-now.” Recovery from PTSD often requires long- term treatment from specially trained clini- cians. Counselors should be prepared to refer these clients to trauma experts. (See also the forthcoming TIP Substance Abuse and Trauma [CSAT in development f].) Clients with phobias can be especially sensitive to social situations and may need help in partici- pating in mutual self-help groups. Specialized approaches, including use of medications, to reduce anxiety-induced insomnia also may be indicated.

People With Infectious Diseases HIV, AIDS, and tuberculosis are more preva- lent among inmates than in the general popu- lation. At the end of 2002, 2 percent of all inmates in State and 1.1 percent of all inmates in Federal prisons were known to be infected with the HIV virus. Rates of HIV infection were higher (3 percent) for female inmates of State prisons than for males (1.9 percent) (Maruschak 2004). In 2002 they were also higher for African-American (1.2 percent) and Hispanic/Latino (2.9 percent) jail inmates than for white jail inmates (.8 percent) (Maruschak 2004). More than a quarter of all inmates known to be HIV-posi- tive in 2002 were held in New York State, amounting to 7.5 percent of that State’s total prison population (Maruschak 2004). According to 2002 data, 0.50 percent of inmates in State prison had confirmed cases of AIDS, three and one-half times the rate for the general population (Maruschak 2004).

Evidence suggests that sexually transmitted diseases (STDs), hepatitis B and C, and tuberculosis also affect inmates dispropor- tionately (Hammet 1998; Hammet et al. 1999; Varghese and Fields 1999). Routine screening for STDs and hepatitis is not included in many correctional systems, and, although HIV prevention programs are becoming more common, few correctional systems have

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implemented systemwide programs to educate inmates about these diseases or to institute preventive measures. High-risk behaviors for the spread of HIV occur with great frequency in correctional facilities. These include unprotected sexual activity, substance use, and tattooing. The data clearly show that there is transmission of HIV between inmates (Hammett et al. 1999). Curricula for HIV prevention are available in many prisons. However, although female inmates have high- er rates of HIV than their male counterparts, few HIV educational programs have been developed for the particular needs of women.

The Federal prison system undertakes ran- dom HIV testing of inmates for data collection purposes, and all inmates are tested on release; otherwise inmates are tested only if there is a clinical indication that they may be HIV-positive or if they request testing. States have various procedures for testing the HIV status of inmates. Some States test all inmates who meet the criteria for belonging to a high- risk group, some test everyone entering the facility, and still others test inmates upon dis- charge from the facility. More information on substance abuse treatment for people with HIV/AIDS can be found in TIP 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT 2000e).

117Adapting Offender Treatment for Specific Populations

Project ARRIVE

Project ARRIVE, a NIDA-funded AIDS prevention training model, was designed specifically for recent- ly released parolees with histories of intravenous drug use—a population particularly vulnerable to resuming high-risk behaviors (Wexler et al. 1994). ARRIVE’s assumption was that reinforcing parolees’ general social and personal rehabilitation could reduce the risk of contracting AIDS. The program incorporated the principles and techniques found to be useful for treating those with substance use dis- orders in other settings.

• Social learning approach to prevention training. The training program emphasized learning skills to resist relapse and develop personal and social competencies (Botvin et al. 1984) and included rational decisionmaking, coping with anxiety, assertiveness, and relaxation skills.

• A strong self-help orientation. Participants were encouraged to accept responsibility for their behav- ior; to develop their capacity to change negative features of their daily lives; and to engender a sense of mutuality, trust, and honesty among participants (Gartner and Riessman 1977).

• Use of principles effective in TC programs (De Leon 1999, 2000; DeLeon and Ziegenfuss 1986). Some ARRIVE training staff were themselves in recovery and could function as role models. In addition, the program fostered the development of peer support networks. Graduates were encouraged to continue their association with the program through weekly aftercare groups.

• Job readiness preparation and placement assistance.

These elements were combined into a structured 8-week, 24-session AIDS prevention program. Each new class met for 2 hours a night, three times per week over an 8-week period. Participants received $10 per session for a total of up to $240 if they attended all 24 sessions. Trainees also were given two subway tokens per session. ARRIVE participants were offered confidential HIV testing and counseling.

During the NIDA study, a total of 394 eligible parolees were recruited, of whom 241 (61 percent) attend- ed the Training Program, including 164 program completers, for a 68 percent graduation rate. (During the second half of the program, 81 percent graduated.) The outcome evaluation, conducted 1 year after study recruitment, compared program graduates with parolees who never attended, controlling for observed group differences at baseline. ARRIVE participation significantly decreased most sexual and some drug-related risk behaviors and improved parolees’ community adjustment during the followup period (Wexler et al. 1994).

While HIV/AIDS is widely recognized as a serious and significant problem within pris- ons, other infectious diseases are not always given the same attention. A vaccine is avail- able for hepatitis B that could control the spread of that disease. However, the preva- lence of hepatitis C virus (HCV) is increasing. In California, 41 percent of incoming prison- ers were positive for HCV in 1994. Prevalence rates among HIV-positive offend- ers are higher (Hammett et al. 1999). Because the incubation period is so long (approximate- ly 20 years), many offenders who have the disease will not experience its effects until after they are released. Consequently, not all prison systems recognize hepatitis C as a problem; nor do they expend costly resources on its treatment. Rates of tuberculosis (TB) have declined since 1991 both in the general population and among incarcerated offend- ers, although they are still higher among inmates. Not all systems routinely screen for TB and report results. There is a risk to cor- rectional employees of contracting TB due to insufficient control measures (Hammett et al. 1999).

Medical Care Research indicates that medical care for offenders in the criminal justice system is inadequate and underfunded, and the burden is increasing as the inmate population ages. This exacerbates poor health habits and neglect of health care not uncommon among

people who come in contact with the criminal justice system. Medical care is extremely important for offenders with substance use disorders, who often have a number of medi- cal problems. While using alcohol and illicit drugs, offenders often ignore their health problems. When they finally enter treatment they could have several problems that have been untreated except for self-medication. If they are in pain they are less able to focus on their substance abuse treatment. As a conse- quence, substance abuse treatment staff often request that the institution pay greater atten- tion to medical issues and advocate for medi- cal services for their clients.

Substance abuse treatment staff also should stress the importance of good health when working with offenders. Health improvement can be included as a goal for clients and writ- ten into their treatment plans.

Prevention and Education Educational programs about infectious dis- eases are a useful addition to a treatment pro- gram but cannot stand alone without counsel- ing and treatment for those diseases. Simply informing a group of offenders about the dan- gers of infectious disease without helping them deal with the possibility of infection can actually cause additional problems, such as fights caused by fears of infection. Prevention and testing efforts often work more smoothly if integrated into a substance abuse treatment

program, as counseling staff can work with an individual and help him or her deal with con- cerns and fears. Programs can use peers who are HIV-positive to provide education to other offenders; in addition to provid- ing other offenders with infor- mation from a credible source, peer education helps the person who is HIV-positive feel that his or her life has some sense of purpose.

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Advice to the Counselor: Infectious Diseases

• Education about infectious diseases such as HIV/AIDS and hepatitis C is a useful addition to a treatment program. However, this education must take care not to cause additional problems such as fights over fear of infection.

• Counseling by peers who are HIV-positive provides infor- mation from a credible source.

• Health improvement can be included as a goal for clients and can be written into their treatment plans.

Sex Offenders Self reports of those incarcerated for rape or sexual assault reveal that 23 percent admitted they were under the influence of alcohol alone when they committed their crime, another 15 percent acknowledged using both alcohol and drugs, and an additional 5 percent reported they had been using drugs alone (CASA 1999). That even these self-report numbers considerably underestimate the pervasiveness of substance abuse among sex offenders is suggested by the fact that 42 percent of those arrested for sex offenses tested positive for drugs at the time of arrest (CASA 1999). Similar evidence for alcohol use is not avail- able but can be presumed to be considerably higher. Among incarcerated sex offenders, two of every three have a history of alcohol or drug use, abuse, or addiction (Peugh and Belenko 2001).

While the high prevalence of substance abuse among sexual offenders is clear, solid infor- mation about the relationship between sub- stance abuse and sexual offending is not read- ily available. While many convicted sex offenders will admit to problems with alcohol or illicit drugs, it is unusual for someone identified with alcohol or drug problems to freely disclose illegal sexual behavior. The negative consequences of such an admission would usually be too great. Consequently, what is known about the co-occurrences of substance use disorders and the commission of sex offenses comes mainly from the person- al history and self reports of identified sex offenders within the criminal justice system and their victims.

Sex offenders apprehended and labeled through the criminal justice system are thought to represent a small portion of those who actually commit sexual offenses (Center for Sex Offender Management 2001a). Only those individuals actually convicted of sexual offenses are likely to be identified as a sex offender subgroup with COD requiring spe- cialized attention. And for this population, the focus of treatment is likely to be the sexu-

ally deviant behavior. Alcohol and drug issues are usually seen as one part of a broad array of problems contributing to the sex offense and specific attention to substance abuse issues may comprise only one of many treat- ment modules designed to address these underlying problems (Barbaree et al. 1998). Many sex offenders with substance abuse issues are excluded from many substance abuse treatment programs. Analysis of Bureau of Justice Statistics data reveals that 34 percent of sex offenders receive drug treat- ment in prison, as opposed to 42 percent of other violent offenders (Peugh and Belenko 2001). Often if they are to get any treatment for their substance abuse problems, it must be in or in conjunction with a sex offender treatment program. Otherwise, to participate in substance abuse treatment, they must con- ceal their sex offender identities and histo- ries—not a promising foundation for fostering the self-disclosure treatment requires.

The subpopulation of sex offenders among offenders who require interventions for sub- stance abuse issues raises many questions and complications, especially since they also may be concurrently mentally ill, culturally diverse, developmentally disabled, or other- wise high need (Raymond et al. 1999). Sex offenders often stir strong emotions and reac- tions (Jenkins 1998). The criminal justice sys- tem, other offenders, and the community at large typically think of sex offenders, particu- larly those whose victims are children, as a different class of criminal. Within jails and prisons, if identified, they are at great risk of being victimized by other inmates (and some- times correctional staff) because of the nature of their crimes. Some States provide sex- offender–specific treatment services for a portion of these inmates, pre- and post- release, and many counties require treatment as one of the conditions of probation (Burton and Smith-Darden 2001). When released from incarceration, sex offenders are required to register with local authorities, often receive more stringent supervision than other offenders, can be subject to community

119Adapting Offender Treatment for Specific Populations

notification procedures, frequently encounter serious problems finding appropriate hous- ing, and may have their identities and pic- tures made available on the Internet (Center for Sex Offender Management 2000a).

Some Relevant Facts About Sex Offenders The image of the typical sex offender con- jured by lurid newspaper headlines bears only some resemblance to the actual picture. The blanket term “sex offenders” includes a population so heterogeneous that only a few generalizations are not inaccurate and mis- leading (Center for Sex Offender Management 2000b). Although once there were thought to be discrete offender types—rapists, child molesters, incest offenders, exhibitionists—an increasing body of evidence derived from polygraph examinations of convicted offend- ers demonstrates that there is considerable “crossover” between behaviors once thought to define these subgroups. Thus nearly 9 of 10 offenders originally thought to have only adult victims were found, under polygraph examination, also to have victims under 18. Similarly, 36 percent of those convicted of an incest offense disclosed that they also had vic- timized adults (English et al. 2000). One important distinction, however, is that sexual offenses committed while intoxicated (e.g., date rape) are unusual occurrences and do not represent habitual behavior. These prob- lems are more about impulse control ampli- fied by alcohol and other substance use and often can be treated in substance abuse pro- grams.

It now is generally accepted that no single causative factor can adequately explain the commission of sexual offenses. Only multi- factorial explanations that take into account the presence, to various degrees, of deviant sexual arousal, lack of victim empathy, inade- quate social skills, personal trauma history, criminal association, thinking errors, and other elements now appear to provide ade- quate models for understanding these crimes.

The use of alcohol and drugs is seen as con- tributing to disinhibition but is never thought to be a stand-alone explanation for sexual offending (Laws et al. 2000).

Sex-Offender–Specific Treatment The emergence, over the past 20 years, of an increasingly solid body of research-based information about sexual offending has led to correspondingly sophisticated treatment mod- els and outcome studies (Marshall et al. 1998). Treatment focus areas are based on an emerging set of “dynamic” (i.e., modifiable) risk variables. One widely used instrument for assessing such factors is the Sex Offender Needs Assessment Rating (SONAR) (Hanson and Harris 2001). Risk factors identified in the SONAR include intimacy deficits, nega- tive social influences, antisocial attitudes, inadequate sexual self-regulation, and general self-regulation. Addressing such factors in non–sex-offender-specific treatment might have some impact on reducing the risk of sex- ual recidivism. A growing body of solid research provides evidence that, overall, treatment now reduces the reoffense rate between 10 and 17 percent (Center for Sex Offender Management 2001b).

Relapse Prevention: The Common Thread With some modifications, relapse prevention concepts and formulations borrowed from the substance abuse treatment field have been found to fit sex offender programming needs quite well (Laws 1989; Laws et al. 2000). At present, relapse prevention—or the more broadly designated cognitive–behavioral ther- apy—has grown to be the dominant model used by most sex offender treatment pro- grams, whether institutional or community- based, so that currently over 80 percent of programs in North America identify “cogni- tive–behavioral/relapse prevention” as their primary treatment model (Burton and Smith-

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121Adapting Offender Treatment for Specific Populations

SHARPER FUTURE

Awareness of the presence of significant numbers of sex offenders among inmates participating in California’s in-prison substance abuse treatment programs—as high as 30 percent—led to the develop- ment of a specialized aftercare program specifically tailored to address both substance abuse and sex offense issues concurrently. For many reasons, in-prison programs do not address sex offense issues. SHARPER FUTURE (Social Habilitation and Relapse Prevention – Expert Resources), a private-sector forensic mental health agency, has been operating a program under contract in central Los Angeles since 1999 to meet the needs of parolees who have completed one of the in-prison substance abuse programs but who are screened out of other aftercare programs because of their sex offense histories. (SHARPER FUTURE also has a component to treat offenders with mental disorders.)

SHARPER FUTURE is staffed by licensed clinicians with expertise in treating both areas concurrently. The existence of many parallels between treatment strategies for substance abuse and for sex offense issues offers a foundation for such an integrated approach. Concepts from relapse prevention apply equally well to both areas of concern.

Because of restrictions in California codes prohibiting registered sex offenders from sharing a common residence, SHARPER FUTURE is exclusively outpatient. As an outpatient program, SHARPER FUTURE cannot fully continue but does support the therapeutic community philosophy that is the foundation of the prison-based system. Although the program is considered “aftercare” for substance abuse issues, which have been directly addressed previously in the institutional setting, the sex offense issues are addressed directly for the first time only in this outpatient phase. During the 14-month inten- sive treatment phase of SHARPER FUTURE, participants, all on parole, attend three 2-hour groups per week. A weekly aftercare group can subsequently continue until the end of the parole period or beyond.

Because personal issues related to substance abuse already have been addressed in prison and because the level of shame related to sex offense behavior generally is much more intense, greater resistance in dealing with the sexual behavior is common. Frequently analogies with substance abuse cycles, behavior chains, thinking errors, low capacity for delayed gratification, and similar themes offer a more accept- able entrance to the sex offense work. Creating a group treatment culture supportive of the work needed to address deviant sexual patterns is essential to treatment success.

Standards of the Association for the Treatment of Sexual Abusers (ATSA—see www.ATSA.com) require substantial training and experience for staff involved in treating sex offenders and finding such qualified staff, especially individuals who also have expertise in substance abuse treatment, has been a challenge, as has working collaboratively within such a large and complex system as the California Department of Corrections. Future goals include replicating this pilot program in other geographical areas and, ulti- mately, developing structures to allow the sex offense issues to be addressed from the beginning of treat- ment in specialized separate tracks of the in-prison substance abuse treatment system. (For more infor- mation go to www.thesharpprogram.com/.)

Darden 2001). Sharing such a common lin- eage has the benefit of permitting easy movement in the treatment setting between relapse prevention as applied to substance abuse and relapse prevention as applied to sex offending.

Areas of Divergence Important differences prevent a simplistic merger of sex offender treatment and sub- stance abuse treatment models. Sex offender treatment usually is provided by specially trained—sometimes specifically creden- tialed—mental health professionals, and interventions can include medical and behav- ioral efforts to modify deviant sexual arousal patterns (ATSA 2001). Stakes are higher because any “relapse” involves another trau- matized victim and can lead to a long, even lifetime, prison sentence. Since the primary goal is community safety, sex offender treat- ment usually involves close collaboration with the criminal justice system, represented by probation and parole officers. Great caution is exercised with regard to encouraging mutu- al support efforts between sex offenders and, consequently, self-help support systems are ordinarily unavailable. Treatment themes sel- dom are discussed freely with support per- sons outside of the program since the stigma and other social consequences of being a sex offender are considerably higher than for those in substance abuse recovery.

Conclusions and Recommendations The consensus panel believes the following points and recommendations merit emphasis:

• The panel recommends that screening and assessment for a history of physical/sexual abuse be included as part of intake assess- ments for men and women in criminal justice treatment settings. Referral information should be provided to inmates who report prior abuse and who are interested in receiv- ing services related to this abuse.

• Use of “strengths-based” approaches to sub- stance abuse treatment is highly recom- mended, particularly for female offenders. These interventions are considered effective in improving self-esteem.

• Substance abuse treatment programs in jails and prisons (including TCs) should include vocational programs for men and women. Offenders under community supervision also should have access to community voca- tional programs.

• Treatment programs in women’s institutions are encouraged to use the segregation of genders within the criminal justice system to the advantage of their clients by develop- ing treatment programs that specifically address women’s needs.

• The panel encourages jail and prison pro- grams to allow for more interaction between incarcerated mothers and their children; the 2–4 hours of supervised visitation per week that many institutions allow is not suf- ficient for mothers or their children.

• Given the high rates of co-occurring mental disorders in the offender population, more treatment programs need to be developed for offenders with COD.

• Given the prevalence of cognitive and physi- cal disabilities in incarcerated populations, especially among offenders with substance use disorders, treatment providers need to be able to screen for and to provide accom- modations for offenders who have these co- existing disabilities.

• Because mental health and substance use disorders can mask or imitate each other, accurate diagnosis of these disorders requires skilled screening and assessment. Assessment should look for evidence of both disorders, rather than providing separate assessments for the disorders. Regular reassessment for COD also is important, and should be conducted at major transi- tion points in the criminal justice system by staff with specialized training in this area.

• Substance abuse treatment programs for offenders should include staff who reflect

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the cultural diversity of the population they are treating. Efforts need to be made to adopt treatment to specific cultural popula- tions (e.g., ethnicity, race, age, sexual ori- entation, rural cultures, socioeconomic class, and language). Counselors need to be aware of different cultural sets of values, biases, and assumptions related to commu- nication, therapeutic style, and interper-

sonal contact and should be trained in tech- niques for adapting treatment approaches to reflect these differences, in order to more effectively engage and maintain clients in program services.

• The therapeutic community has been suc- cessfully modified to treat specific popula- tions, including female offenders and offenders with COD.

123Adapting Offender Treatment for Specific Populations

125

7 Treatment Issues in Pretrial and Diversion Settings

In This Chapter…

Introduction

Characteristics of the Population

Treatment Services in the Pretrial Justice System

Trial and Postverdict Periods

Diversion to Treatment

What Treatment Services Can Reasonably Be

Provided in the Pretrial Setting?

Treatment Issues

Developing Pretrial Treatment Services

Resources

Conclusions and Recommendations

Overview The pretrial period of criminal justice processing is unique in that for most people it is brief and the outcome is uncertain. Yet, it represents an opportunity to identify those who could benefit from substance abuse treatment and begin to engage them in the process. Providing effective ser- vices at this early stage of involvement with the criminal justice system can result in heightened motivation to seek treatment and decreased recidi- vism.

After characterizing the population of arrestees, this chapter describes the processes of arrest, arraignment, plea bargaining, trial, presentenc- ing, and sentencing. Diversion to treatment can occur at several points during the pretrial phase. Several types of diversion, including drug treatment courts, are discussed. The chapter continues with a discus- sion of some of the strategies that are effective during the pretrial stage, as well as some of the issues that are specific to it. Some of the qualities of effective pretrial and diversion programs are the next topic: the staff resources, training, coordination, program components and proce- dures. Finally, the chapter describes several existing diversion pro- grams and lists resources, research findings, and conclusions.

Introduction There are several challenges in developing treatment interventions dur- ing pretrial criminal justice processing and the presentencing phase. A large number of offenders move relatively quickly through the system, and many different agencies are involved with each case and supervi- sion. At the pretrial stage, offenders have been charged with a crime, not convicted, and involvement with treatment may or may not be in the offender’s legal interests. The trauma and uncertainty of the arrest can either help or undermine motivation for treatment. Diversion to treat- ment can occur at several points before incarceration. The offender may opt for treatment in lieu of incarceration or to reduce the length of incarceration by participating in treatment.

Variations in local prosecution and diversion practices may affect a jurisdiction’s ability to develop the criminal justice treatment link- ages presented in this chapter. Not all juris- dictions have established procedures or pro- grams for clients who abuse substances; those jurisdictions that do have programs to treat offenders often maintain such programs with limited resources. Recognizing the disparities between available treatment programs for offenders, the consensus panel posited the fol- lowing observations as a starting point for discussions of treatment in pretrial and diver- sion settings.

• Expanding and institutionalizing pretrial treatment services are important goals. The pressure of overcrowded jails and prisons is expanding and institutionalizing programs for drug treatment in pretrial and diversion settings nationwide. In the past, the criminal justice system and the treatment community have often operated independently, but the advent of drug courts and other diversion programs has created a better climate for col- laboration.

• Treatment remains a low priority in the crim- inal justice system at the pretrial stage, although it has been credited with helping to reduce criminal behavior. Each jurisdiction decides what priority to give substance abuse treatment and whether it merits significant financial resources. Outside of formal drug court and diversion programs, treatment access is limited.

• Pretrial defendants are often uncertain as to the status of their case and experience signifi- cant disruption related to their arrest. The uncertainty of their case disposition influ- ences a counselor’s ability to engage an indi- vidual in treatment. For example, defendants may be unsure whether treatment will be required by the court as part of their sen- tencing arrangements, or whether voluntary pretrial involvement in treatment would be more rigorously monitored than standard probation that they would receive as an alter- native to involvement in diversion programs. For some, the arrest provides strong motiva- tional leverage to engage individuals, while for others, the stress related to arrest and lack of clarity regarding their case disposition makes offenders less receptive to treatment.

This chapter highlights some of the innovative programs to treat offenders and the issues that substance abuse treatment and criminal justice personnel are likely to encounter when treating clients in a pretrial or diversion setting.

Characteristics of the Population In 2000, the Arrestee Drug Abuse Monitoring Program (ADAM) collected data on male arrestees from 35 urban sites (National Institute of Justice 2003). Of the male arrestees tested and interviewed, more than 50 percent from every site tested positive for at least one

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National Arrest Highlights in 2003

• Estimated total U.S. arrests: 13,639,479.

• Number of arrests for drug law violations: 1,678,192.

• Number of arrests for driving under the influence: 1,1448,148.

• 83.7 percent of arrestees were aged 18 or older.

• 46.3 percent of arrestees were under age 25.

• 76.8 percent of arrestees were male.

• Drug arrests rose 22.4 percent between 1994 and 2003 while total arrests declined 2.8 percent.

• Between 1994 and 2003 the number of females arrested increased by 12 percent while the number of males decreased by 7 percent (FBI 2004).

drug. Marijuana was the drug detected most frequently, followed by cocaine.

In the 29 sites where data were collected on women, more than half tested positive for at least one drug. Unlike the male arrestee pop- ulation, cocaine was most frequently detected among female arrestees, followed by marijua- na and methamphetamine (National Institute of Justice 2003).

Nationally, 65 percent of all arrestees test positive for an illicit drug. Seventy-nine per- cent of arrestees are “drug-involved,” mean- ing they tested positive for a drug, reported that they had recently used drugs, had a his- tory of drug dependence or treatment, or were in need of drug treatment at the time of their arrest (Belenko 2000).

Approximately 13.6 million arrests were made in 2003, including 1.7 million for drug viola- tions, the largest category of arrests. Seventy- seven percent of all the individuals arrested in the United States during 2003 were male. This represents a 0.4 percent drop in the arrests of males and a 1.9 percent increase in the number of arrests of females compared to 2002 figures. Drug- and alcohol-related arrests occurred at a rate of 1,470 per 100,000—the most numerous of crime types (Federal Bureau of Investigation [FBI] 2003).

In 2003, of arrests nationwide, 71 percent were Caucasian, 27 percent were African American, and the remainder were of other races. Race distribution figures also showed that Caucasians accounted for 68 percent of the property crime arrests, and 61 percent of the violent crime arrests (FBI 2003).

Despite the common assumption that most offenders are incar- cerated shortly after arrest, studies show that the majority of drug-involved offenders are supervised in the community fol-

lowing arrest. For example, in 1996 in large urban areas, 62 percent of drug traffickers and 71 percent of other drug offenders were released before trial (Dorsey and Zawitz 1999).

The Need for Treatment Services Very few arrestees were in treatment at the time they entered the criminal justice system, yet 24 percent of those interviewed for the ADAM study in 1997 indicated that they need- ed treatment. Thirty-six percent of arrestees reported use of cocaine, but only 6 percent had ever received drug treatment (National Institute of Justice 2000).

Treatment Services in the Pretrial Justice System The process through which an accused individ- ual moves from arrest to full discharge of a sen- tence has many decision points, each with many variations from jurisdiction to jurisdic- tion, and each with many decisionmakers and possible decision outcomes.

127Treatment Issues in Pretrial and Diversion Settings

Advice to the Counselor: General Considerations for Working With Clients in the

Criminal Justice System • Treatment should not compromise the due process rights

of defendants.

• Treatment professionals should bear in mind the pre- sumption of innocence that exists during the pretrial period.

• Defendants’ due process rights are of vital interest and affect what they are willing to agree to and the type of information that they are willing to disclose.

• Defendants should not be coerced into waiving due pro- cess rights.

Arrest Arrest is the taking of a suspect into legal cus- tody by police, probation or parole officers, or other authorized officials. Arrest may be authorized pursuant to a judicial warrant, which is issued when there is probable cause to believe that a crime has been committed and that the suspect committed the crime. Arrest without a warrant may be made by a police officer when there is probable cause to believe a felony was committed by the sus- pect. Arrests for misdemeanor violations gen- erally require a warrant, except when the arresting officer sees the suspect committing the misdemeanor (e.g., in some cases of drug possession). Police have some discretion in whether to make arrests, although some juris- dictions have mandated arrest in certain situ- ations, such as domestic violence or drunk driving.

For many individuals, further involvement in the criminal justice system might be prevent- ed if police were informed about substance abuse and empowered to make referrals to a responsive treatment system. The consensus panel suggests that, when possible, police offi- cers should use their community contacts to explore substance abuse treatment services options for individuals involved with sub- stances who come to their notice but who are not arrested.

From a treatment perspective, arrest and the related crisis may have a positive outcome. Arrest can be a significant event in a person’s life, and for offenders whose arrest was relat- ed to their substance abuse, the event might make it difficult for the person to deny sub- stance abuse problems. Arrest offers the opportunity for the individual to voluntarily choose to enter substance abuse treatment. Thus it is important for connections to be made between the treatment and criminal jus- tice systems at this point. Representatives from both the criminal justice and substance abuse treatment systems can view arrest as an important point from which to establish link- ages, engage the defendant in interventions, and promote collaboration between the sys- tems.

It must be noted, however, that involvement of substance abuse treatment providers at the point of arrest may raise constitutional issues. If the arresting officer transfers the individu- al to substance abuse treatment rather than to the criminal justice system (which has laws protecting defendants’ rights), questions may be raised about due process, civil liberties, and extension of the criminal justice system beyond permissible bounds. Once an individ- ual has been arrested, the defendant is sub- ject to the authority of the criminal justice system even if he or she has been transferred to treatment. The level of responsibility granted to the treatment program should be

defined clearly, understood by both systems, and incorporated into the information flow between systems.

Arraignment Arraignment is a technical term signifying presentation of the charges to the defendant. In many jurisdictions the term is reserved in felony cases for the presentation of charges in supe- rior court. A first appearance is held in the lower court after arrest for bail setting and proba-

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Advice to the Counselor: Diversion to Treatment Decision Points • Diversion to treatment can take place at several points in

the criminal justice process:

> After arrest and prior to initial arraignment or bail hearing

> After initial arraignment appearance or bail hearing

> After preliminary hearing/probable cause hearing

> After guilty plea but before sentencing

> After conviction and sentencing, with sentencing sus- pended pending treatment completion

ble cause review. This hearing is not referred to as an arraignment.

The period of time between arrest and arraignment is a window of opportunity to intervene and articulate the value of sub- stance abuse treatment. Drug testing, screen- ing, and assessment for substance abuse and dependence, needs assessment in other areas, and relapse prevention are important compo- nents of intervention at this time as well as at other points along the continuum. The con- sensus panel recommends a multidisciplinary approach, with treatment providers available to work with police and court personnel to guide offenders who abuse drugs into treat- ment.

During arraignment, charges are brought against the defendant, and the defendant is informed of his rights. The defendant then enters a plea in response. Additional person- nel, including staff from pretrial service agen- cies, judges, prosecutors or defense attor- neys, court referral officers, and representa- tives of referral systems, handle this process and become involved as the defendant moves through the arraignment process. Each of these individuals can refer the defendant to substance abuse treatment services.

As a result of the arraignment, a defendant can be released on his or her own recog- nizance (i.e., a sworn promise to return); detained pending the posting of a certain amount of bail; detained with no bail (very unusual); or released under certain condi- tions, such as keeping a curfew, reporting periodically to a supervising officer, or wear- ing an electronic tracking device.

Pretrial Diversion: Supervision in Lieu of Detention An increasingly common condition of release is participation in some form of treatment in which a pretrial supervision agency or proba- tion department monitors compliance. Should the individual fail to comply with the condi- tions of release, he or she can be returned to

jail for detention prior to trial. Successful completion of the treatment or other condi- tions can mitigate the sentence imposed by the court if the offender is convicted. The consen- sus panel recommends that, ideally, judges should mandate as a condition of release that offenders receive treatment within 24 hours.

Pretrial Diversion: Treatment in Lieu of Prosecution In some instances, arrest charges against the defendant are dropped if the person com- pletes treatment. The decision to order treat- ment as part of pretrial diversion typically, though not always, rests with the prosecutor’s office. The prosecutor offers to cease all pros- ecution of the case if the defendant completes the prescribed treatment regimen. However, if the defendant fails to complete the treat- ment and to satisfy the other conditions of diversion, he may risk being sentenced more harshly (if prosecution proceeds and a con- viction results) than if the individual had never entered the diversion program.

Because pretrial diversion occurs before an individual enters a guilty plea or is convicted by a judge or jury, the defendant is still tech- nically innocent. Anxiety about the outcome of pending charges may motivate those charged to agree to treatment, and many treatment providers view this as an ideal time to intervene and offer the individual an opportunity to participate in treatment.

Plea Bargaining With court docket overcrowding, plea bar- gaining is used in a large number of cases. In a plea bargain, defendants are allowed to plead guilty to lesser charges than the charges that they would have had to face at trial. In most cases, especially misdemeanors or low- level or nonviolent felonies, the sentence is agreed to by prosecutor and defense attorney as part of the plea bargaining agreement. So although judges have the power to change the

129Treatment Issues in Pretrial and Diversion Settings

sentence, they generally do not do so except in unusual circumstances.

Incorporation of substance abuse concerns into the plea bargaining process is a key ele- ment in strategies to link the justice and treatment systems. A requirement that the defendant enter treatment can be part of the plea bargain. Many systems are finding that getting defendants into treatment at this point is successful because they are ready for ser- vices. However, just as overcrowded court dockets force the hand of criminal justice sys- tem officials on certain decisions, overcrowd- ed caseloads can make it difficult for treat- ment programs to accept new clients. In some cases, defendants who are placed on waiting lists for treatment can be involved in sub- stance abuse education or treatment orienta- tion groups, so that they do not lose track of

the need for recovery and treatment involve- ment.

Pretrial Diversion: Probation Before Judgment Another form of pretrial diversion is Probation Before Judgment. Under this scheme, the defendant is placed on probation (usually unsupervised) and the charges are pending. If the probation is completed successfully (which may include court-ordered treatment) then the charges may be dropped. This happens com- monly in regular traffic court but can be used as a mechanism within diversion programs as well.

Trial and Postverdict Periods

Trial A trial is a court hearing in which a prosecutor presents a case against the defendant to show that he or she is guilty of a crime. The defendant presents information to support the plea that he or she is not guilty. A judge or jury decides the verdict.

Presentencing Presentencing is the period after a guilty plea is entered (in cases that are plea bargained) or after a conviction is handed down (in cases that go to trial).

Prior to sentencing, a presen- tence investigation is usually conducted. The investigation is conducted after the plea is entered or after the conviction is handed down. In some plea-bar- gained cases, a plea may be with- drawn after the presentence investigation is completed and

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Advice to the Counselor: Information Management During the Pretrial Stage

• Information management is the key to identifying treat- ment needs and can provide treatment and related ser- vices during the pretrial stage more effectively.

• Because of the complexity of the pretrial phase (with many different agencies involved in a short or uncertain time period), it can be difficult to access necessary infor- mation on a timely basis. Also, treatment providers may not be permitted to provide certain information regard- ing clients to criminal justice staff. As a result, the infor- mation needed for clinical or case decisions may not be available at the appropriate time.

• Pretrial information about a defendant can be grouped into the following categories:

> Criminal record

> Prior compliance with supervision

> Pretrial evaluation

> Substance abuse assessment information

> Substance abuse treatment information

> Mental health treatment

> Relevant medical information

sentencing recommendations are made. However, in some jurisdictions, the prosecu- tion conducts an investigation prior to making the plea offer, thereby preventing the prob- lem of changes in plea at the sentencing stage.

Many jurisdictions have presentence investi- gation agencies that specialize in writing the presentence report. Elsewhere, probation officers compile the report. The sentence or penalty handed down by the judge is based on the information compiled in the report. Therefore, with more relevant information available, the judge is better equipped to make an appropriate sentencing decision.

This is another point where linkages between the substance abuse treatment and criminal justice systems are crucial. It is suggested that some sort of preliminary assessment be con- ducted at this stage, if one has not yet occurred in the earlier stages.

In many States, serious legal constraints pre- clude sharing information contained in the presentence investigation. In some States, only the judge can see the report—not even the defendant can see it. However, the pre- sentence investigation report may contain information highly relevant to developing a substance abuse treatment plan for the indi- vidual. To avoid duplication of efforts in gathering needed information at various stages of the justice-treatment continuum, planners should investigate ways to ensure that critical information follows the individu- al through the process without breaching con- fidentiality. (For more information on confi- dentiality, go to www.hipaa.samhsa.gov and see CSAT 2004.)

Sentencing If the verdict is “guilty,” either the judge or the jury, depending on the State, determines the sentence or the penalty imposed in the case. In many States, the sentence or penalty is based partially on the information that has been com- piled in the presentence investigation report. Increasingly, States are passing laws to ensure

that the penalty is based on the offense without regard to information contained in the report. Laws requiring the sentence to be based on fixed criteria are known as sentencing guide- lines, and their purpose is to eliminate wide judicial discretion that can result in disparate sentences by jurisdiction within a system or even by courtroom. However, these guidelines allow for very little flexibility based on defen- dant-specific factors such as substance use or mental disorders.

Diversion to Treatment Much of the substance abuse treatment that occurs in the pretrial setting is in the form of diversion from prosecution into treatment. In other cases, diversion is conducted after con- viction but before sentencing. This model is used extensively by drug treatment courts (DTCs) (see description below) and provides safeguards so that prosecutors can effectively reinstate charges for those individuals who are unsuccessfully terminated from diversion programs. Diversion is a “multi-systems col- laboration between criminal justice and com- munity-based agencies [that] allows programs to begin to address potential contributing fac- tors to recidivism” (Broner et al. 2002, p. 87). It is a “mechanism to identify those in need of treatment, to broker treatment, hous- ing, medical care, vocational and educational training, and often to remain involved with the individual . . . in the community” (Broner et al. 2002, p. 97). DTCs are a primary mech- anism through which offenders are diverted into treatment. Diversion to treatment depends to a large extent on the statutory framework that guides processing defendants and on the prosecutor’s approach to resolving cases through placement in treatment.

Drug Treatment Courts In communities throughout the United States, DTCs are dramatically changing the way the criminal justice system deals with offenders who use drugs. Drug courts and other diver- sion programs hold considerable promise for

131Treatment Issues in Pretrial and Diversion Settings

engaging and retaining offenders who are involved with drugs in treatment and related services. DTCs share the underlying premise that drug abuse is not simply a criminal jus- tice system problem, but a public health problem. American University’s Drug Court Clearinghouse and Technical Assistance Project documents over 1,000 operational drug courts as of December 2003, with many more in the planning process. (See TIP 23, Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing [Center for Substance Abuse Treatment {CSAT} 1996].) Preliminary out- come research indicates that DTCs are effec- tive in engaging and retaining offenders in treatment and can significantly reduce crimi- nal recidivism during program participation and following release from the DTC (Belenko 2001). Successful implementation of DTCs has stimulated the development of several other “specialty court” approaches for sub- stance-involved populations, including DUI/DWI courts, juvenile drug courts, and family drug courts. Each of these specialty courts uses a collaborative rehabilitation team model that involves the judiciary, treat- ment providers, community supervision, and ancillary community services.

DTCs were established in response to the realization that incarceration for longer peri- ods and under mandatory sentencing laws was not having a significant effect on drug- using behavior. Instead, the courts, jails, and prisons were becoming more and more con- gested. DTCs provide diversion from jail or prison through expedited involvement in treatment for nonviolent offenders with sub- stance abuse problems. Some drug courts have now expanded their admission criteria to include offenders who have a history of multiple prior offenses related to their sub- stance abuse. Several different diversion models are used by DTCs (some operating within the same jurisdiction), including pre- sentence diversion, processing through post- plea or presentence arrangements, and post- conviction arrangements. The essential “core” of DTCs is a collaborative partnership

between the courts, substance abuse treat- ment providers, community supervision, and other ancillary services to achieve sustained participation in treatment, coupled with regu- lar oversight and monitoring by the court. In contrast to the adversarial nature of tradi- tional criminal court processing with its focus on prosecution of cases, DTCs feature more of a rehabilitation team approach that cou- ples mandatory treatment involvement with accountability through surveillance, monitor- ing, and regular feedback to the court and drug court team. Drug courts provide more rigorous supervision and accountability than is provided for offenders on traditional pro- bation.

Typically drug court planning and oversight teams determine the DTC structure, treat- ment delivery model, and selection of treat- ment providers. A DTC team consists of judge, prosecutor, defense counsel, treatment provider, corrections personnel, local social service and mental health representatives, and housing authorities to help in the design of the most responsive treatment model possi- ble. Though DTCs vary, the goal is essentially the same: treatment for offenders dependent on drugs instead of incarceration or proba- tion (CSAT 1996; Hora et al. 1999).

Figure 7-1 (p. 134) depicts the role of DTCs in substance abuse treatment and highlights the importance of creating and maintaining cooperative working relationships between the substance abuse treatment and criminal justice systems. It is vital that information flow smoothly among the courts, case manage- ment staff, and substance abuse treatment professionals. Judges must have access to evaluation and screening reports, drug screens, and information about the client’s participation in treatment. At the same time, substance abuse treatment counselors, social workers, and mental health professionals involved with the client’s case must be aware of any requirements or restraints imposed by the courts. Figure 7-1 also demonstrates the need for evaluation and reevaluation. During the treatment and recovery process, the

132 Chapter 7

client’s level of functioning, mental health sta- tus, and physical condition may change along with his treatment needs. Continual monitor- ing will allow both systems to tailor treatment to the client’s stage of recovery by identifying and addressing emerging health or mental health issues.

In DTC proceedings, the judge takes an active and leading role in monitoring the offender’s progress in the treatment process through mandatory court appearances and data from urinalysis. The judge encourages the offender to stay in treatment through graduated rewards and sanctions. Generally, treatment lasts about a year, although incen- tives and sanctions can shorten or lengthen this time (Hora et al. 1999).

Treatment through drug courts usually con- sists of three or four phases:

• Orientation, drug education

• Treatment

• Relapse prevention, educational/vocational services

• Aftercare and transition

A range of treatment interventions is employed in DTCs. Most use a tapered approach that employs intensive outpatient treatment during initial stages of treatment, followed by progres- sively less intensive involvement in outpatient treatment (e.g., 1–3 times per week) in later stages of the program. In addition to regular involvement in treatment, DTC clients attend regular status hearings in court, receive indi- vidual and group counseling, are involved in case management services, are drug tested, and participate in peer support groups and a range of other ancillary services.

Other Diversion Models

Treatment Accountability for Safer Communities (formerly Treatment Alternatives to Street Crime) (TASC) TASC programs focus on providing a bridge between treatment providers and the criminal justice system and offer a range of services, including screening and assessment, referral

133Treatment Issues in Pretrial and Diversion Settings

10 Key Components of Drug Courts

The following components were developed by a national committee of experts for the Office of Justice Programs, Drug Courts Program Office (National Association of Drug Court Professionals 1997).

• Drug courts integrate alcohol and drug treatment services with justice system case processing.

• Using a nonadversarial approach, prosecution and defense counsel promote public safety while protecting participants’ due process rights.

• Eligible participants are identified early and promptly placed in the drug court program.

• Drug courts provide access to a continuum of alcohol, drug, and related treatment and rehabilitation services.

• Abstinence is monitored by frequent alcohol and illicit drug testing.

• A coordinated strategy governs drug court responses to participants’ compliance.

• Ongoing judicial interaction with each drug court participant is essential.

• Monitoring and evaluating achievement of program goals is necessary to gauge effectiveness.

• Continuing interdisciplinary education promotes effective drug court planning, implementation, and operations.

• Forging partnerships among drug courts, public agencies, and community-based organizations generates local support and enhances drug court program effectiveness.

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135Treatment Issues in Pretrial and Diversion Settings

Figure 7-1 Substance Abuse Treatment Planning Chart for Treatment-Based Drug Courts

to community-based services, monitoring of treatment progress and compliance, case management and brokering community ser- vices, and court liaison. TASC programs sometimes are embedded with treatment agen- cies or court services departments, and, in some cases, are freestanding organizations. TASC programs have a long history of collab- orative work in the criminal justice system. Early evaluations of TASC programs were generally positive, although limited in scope. An evaluation of five TASC programs (one for juvenile offenders) found mixed results. While TASC programs were consistently suc- cessful in identifying offenders who abused drugs and referring those offenders to treat- ment, three of the sites outperformed the oth- ers in at least one measure of subsequent drug use, while results on criminal recidivism were inconclusive. Study authors report that the findings on TASC programs were “consis- tently favorable,” although modest and, in some cases, confined to offenders with more problematic behavior (Anglin et al. 1999).

Diversion programs estab- lished through constitutional ballot initiatives A number of ballot initiatives have been approved by the electorate in Alaska, Arizona, California, Oregon, and other States that have significantly affected the way in which drug offenses are processed in the criminal justice system. Several of these ini- tiatives have focused on use of marijuana for medical purposes and decriminalization of drug possession offenses. Others, such as Proposition 200 in Arizona and Proposition 36 in California, have been more far reaching and require diversion to treatment for non- violent drug offenders who meet certain eligi- bility criteria. Similar initiatives are sched- uled to appear on the ballot in other States. These ballot initiatives also restrict the use of sanctions (e.g., jail incarceration) that can be applied and provide procedural safeguards to prevent incarceration. These initiatives have been perceived in some jurisdictions as a

direct threat to other existing diversion pro- grams such as drug courts. A preliminary study of the Arizona initiative indicates that significant savings were provided to taxpayers in the form of reduced demand for jail and prison space.

Proposition 36: The Substance Abuse and Crime Prevention Act In November 2000, California voters approved a ballot initiative, Proposition 36 (Substance Abuse and Crime Prevention Act [SACPA] of 2000). The intent of SACPA was to reserve space in prisons and jails for seri- ous and violent offenders, to increase public safety through reduction of drug-related crime, and to expand treatment and rehabili- tation for offenders involved with drugs. The SACPA initiative changes State law to provide substance abuse treatment and community supervision for certain groups of nonviolent drug-involved adult offenders who would oth- erwise be sentenced to institutional settings or supervision in the community. All offenders charged with nonviolent drug-related offenses are potentially eligible to receive treatment services through the initiative. Offenders who use a firearm during the commission of their offense, who have additional nondrug offens- es, or who refuse drug treatment as a condi- tion of probation are ineligible for SACPA participation. The initiative establishes the Substance Abuse Treatment Trust Fund and provided $60 million for fiscal year 2000–2001, and $120 million for each subse- quent fiscal year, ending in 2005–2006.

Although the long-term effects of SACPA await examination in the future, early studies provide information about the people being served. Compared to non-Proposition 36 clients in treatment, Proposition 36 clients were more likely to be men in their first treat- ment episode receiving outpatient services for methamphetamine and marijuana use. They were less likely to use heroin or injection drugs (Hser et al. 2003). Another study

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indicated that criminal justice clients (whether or not they came from Proposition 36) with high-severity drug abuse were less likely to be admitted to residential programs. Of high-severity outpatient clients, the SACPA clients were more likely to be re- arrested for a drug-related offense (Farabee et al. 2004).

Diverting individuals with co-occurring disorders People with some types of mental disorder are more frequently jailed than sent to hospitals. About three quarters of these individuals also have a substance use disorder (Broner et al. 2001a). Their multiple problems present a challenge to criminal justice personnel.

Some of these individuals are good candidates for diversion in the approximately 50 jail- based diversion programs that currently exist. Arrestees with co-occurring disorders can enter a diversion program in either the pre- or postbooking phase. In prebooking diversion, the police officer is the decision- maker, although few police departments pro- vide training in specialized responses to those with mental disorders. In postbooking diver- sion, there is usually screening, mental health evaluation, and negotiation between diversion and legal staff for a diversion rather than prosecution. In some postbooking programs, drug court procedures for case management have been adapted for a population with co- occurring disorders. In others, a “mental health court,” based on the drug treatment court model, has been established. These courts focus on the mental disorders rather than on prosecution.

Many of those with co-occurring disorders do not respond well to traditional community interventions; their problems are too com- plex. It is clear that integrated treatment is more effective than either parallel treatment of mental disorders and a substance use dis- order or sequential treatment of the two (Weiss and Najavits 1998). Drake et al. (1998b) concluded that treatment outcomes

were especially improved when treatment lasts 18 months or longer.

Work by Steadman and colleagues (1995) notes six central features of effective diver- sion programs for offenders with co-occurring disorders: integrated services, key agency meetings, boundary spanners, strong leadership, early identification, and distinctive case man- agement. Boundary spanners in this con- text are individuals with knowledge of both criminal justice and treatment sys- tems who can bring the systems together to collaborate on the shared goal of obtaining substance abuse and mental health treatment for an individual who must answer to restrictions set by the criminal justice system.

Driving Under the Influence courts Recent evaluations of drug court programs throughout the United States (Belenko 2001), which work to rehabilitate drug offenders, reduce recidivism, and save money, indicate that they are achieving their goals. This suc- cess has prompted practitioners and various institutions such as the National Association of Drug Court Professionals and the U.S. Department of Justice to discuss the potential benefits of widespread use of Driving Under the Influence (DUI) courts. Although arrests for DUI have been on the decline since 1987, serious, habitual abusers of alcohol remain largely unaffected by stiff criminal penalties and public awareness campaigns to stop

137Treatment Issues in Pretrial and Diversion Settings

Recent

evaluations

of drug court

programs

throughout the

United States

indicate that they

are achieving their

goals.

drunk driving (National Drug Court Institute 1999).

Similarities between repeat DUI and drug offenders have led many practitioners to believe that DUI or combined DUI/Drug Courts can be effective. Both types of offend- ers have a serious substance abuse problem and both require treatment, a strong support system, and the ability to overcome denial.

However, unlike drug offenders, DUI offenders tend to be employed, and because of their generally more stable family situations, they tend to be able to draw on greater emotional and financial resources. But perhaps the most significant dif- ference between the two is that DUI offenders usually believe that because the substance they ingest is legal, they do not have a sub- stance abuse prob- lem (National Drug

Court Institute 1999).

In November 1998, practitioners from seven legal jurisdictions formed the DUI/Drug Court Advisory Panel at the invitation of the National Drug Court Institute to discuss establishing DUI courts that are modeled after drug courts and/or expanding existing drug courts to include DUI cases. The panel also addressed the many barriers to achieving this goal, including a lack of funding, a nega- tive “soft on crime” perception held by the public, delayed adjudication, and minimal incentives for offenders to enter treatment (e.g., reduced or suspended jail time) (National Drug Court Institute 1999).

What Treatment Services Can Reasonably Be Provided in the Pretrial Setting? The large number of offenders who are super- vised in the community, time constraints, supervision issues, and multiple agencies limit the services that can reasonably be provided in the pretrial setting. Below is a general description of intervention strategies and treatment components recommended by the consensus panel that can be used in a pretrial setting.

Intervention Strategies A number of intervention strategies can be adapted to the pretrial setting, as described in the following section. The time required to implement these strategies is necessarily brief.

Brief interventions For some offenders, especially during the pre- trial stage, a brief intervention can determine if treatment is necessary. Addressing a sub- stance use disorder even briefly is preferable to ignoring it. A counselor can use the FRAMES approach or other motivational enhancement strategies, for example.

• Feedback is given to the individual about personal risk or impairment.

• Responsibility for change is placed on the participant.

• Advice to change is given by the clinician. • Menu of alternative self-help or treatment

options is offered to the participant.

• Empathic style is used by the counselor. • Self-efficacy or optimistic empowerment is

engendered in the participant.

TIP 34, Brief Interventions and Brief Therapies for Substance Abuse, describes

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For some

offenders,

especially during

the pretrial stage,

a brief

intervention can

determine if

treatment is

necessary.

other brief interventions in more detail (CSAT 1999a).

Behavior contracts Some treatment programs use contracts with clients that describe precisely what is required of them. For example, offenders may be placed under less restrictive conditions of supervision if they successfully complete a pretrial treat- ment program. These behavior contracts offer rewards or incentives for specific behaviors. In drug court, individuals move to the next phase only when they complete the requirements in their contracts. Contingency contracts can reduce relapse and improve retention in treat- ment (Prendergast et al. 1995).

Sliding scale (client fees) Many drug courts and pretrial diversion pro- grams require participants to pay treatment or diversion fees in order to participate. Often these are based on ability to pay, or clients are allowed to defer some payments until after they become employed, one of the principles being that charging fees gives the offender some “buy-in” to the treatment process.

Treatment Modalities In addition to previously discussed drug treat- ment courts and related specialty court/diver- sion programs, several other types of treatment modalities can be used effectively in pretrial settings.

Sobering stations Willamette Family Treatment Services in Eugene, Oregon, offers a Sobering Station, a 24-hour facility designed as a safe and clean facility where an individual can be monitored while coming off drugs or alcohol. The service is not detoxification. The individual is housed and monitored until he can leave safely. Those admitted to the Sobering Station are offered detoxification services when appropriate.

Detoxification Detoxification is the term used to describe the process of withdrawal from alcohol or drugs that cause physical addiction. Detoxification, as the word implies, entails a clearing of “tox- ins” from the body. The most immediate pur- pose is to safely alleviate the short-term symptoms of withdrawal from chemical dependence, including physical discomfort.

Detoxification may occur in either an inpa- tient or an outpatient setting. It involves sev- eral procedures for therapeutically super- vised withdrawal and abstinence over a short term (usually 5 to 7 days but sometimes up to 21 days), often using pharmacologic treat- ments to reduce client discomfort and reduce medical complications such as seizures. It is a first step for many clients who will enter treatment, but it is not synonymous with com- prehensive, ongoing treatment. The detoxifi- cation process entails more than the removal of alcohol and illicit drugs from the body; it includes a period of psychological readjust- ment that prepares the individual to enter ongoing treatment.

Withdrawal from certain drugs such as seda- tive-hypnotics, alcohol, benzodiazepines, and barbiturates can be life threatening. Thus, it is recommended that medical detoxification be provided for these classes of drugs. Though not life threatening, opioid withdraw- al should also be treated in order to provide humane conditions to inmates and to avoid the potential for morbidity from dehydration as well as suicide attempts. TIP 19, Detoxification From Alcohol and Other Drugs (CSAT 1995a), describes clinical detoxifica- tion protocols for a variety of substances (see also the forthcoming revision of TIP 19, Detoxification and Substance Abuse Treatment [CSAT in development a]).

Day reporting centers Day reporting centers are used to monitor the behavior of arrestees in the pretrial setting and of probationers and parolees under com-

139Treatment Issues in Pretrial and Diversion Settings

munity supervision. They provide closer supervision than twice-a-week drug testing, but are less restrictive than residential treat- ment.

Additional treatment components The vast majority of offenders processed through the criminal justice system during the pretrial phase have chronic substance prob- lems, as well as high rates of vocational, social service, educational, mental, and phys- ical health needs. The following components can be an important and useful adjunct to standard counseling services offered in the pretrial setting and treatment providers may need to contract these services out on an as- needed basis.

• Vocational training

• Job readiness assessment and preparation

• Liaison with employer

• Literacy assessment and referral

• Anger management training

• Criminal thinking assessment and treatment

• HIV education (sexual health)

• Assistance in accessing State or Federal enti- tlements such as Medicaid; Temporary Assistance for Needy Families; Women, Infants, and Children Program; Food

Stamps; and housing programs available for clients willing to enter treatment

These additional services are integral to fos- tering long-term recovery but they do add cost, more service and supervision layers, and the need for case management. In the long run, however, treatment can save greater costs to the criminal justice, medical, and fos- ter care systems. In a Philadelphia study of Medicaid clients receiving outpatient treat- ment with “enhanced services” (supplemental health and social services), McLellan and col- leagues (1998) found that on almost all out- come measures, the clients receiving the sup- plemental services showed the best outcomes, including drug and alcohol use.

Use of Sanctions Judges and prosecutors have seen that sanc- tions encourage participation in treatment and are necessary to gain public acceptance of treatment in lieu of punishment. Sanctions include a range of measures that focus on holding offenders accountable for their actions. When a system of sanctions is imple- mented in concert with a sound treatment plan, offenders swiftly experience real conse- quences of their actions. This accountability is achieved through graduated sanctions. For example, an offender in an outpatient pro- gram requires drug testing three times per week. After a first positive drug test, the

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Chicago, Illinois, Day Reporting Center

A day reporting center established in Chicago supervises detainees awaiting trial, ensures appearance in court, and begins to address substance abuse and other service needs. The program consists of a manda- tory 15-day orientation phase, from which detainees progress into one of several tracks based on assessed needs. Several challenges in developing the day reporting center include (1) time limitations that restrict the type of interventions that can be provided, (2) facility limitations related to space and treatment activities, and (3) the need to integrate assessment and treatment information within the judi- cial process and to communicate in a timely manner about security and clinical issues. One interesting outcome related to the day reporting center is that approximately half of participants left the program when they were no longer required by the court to remain, with those leaving no longer involved in com- munity treatment services. Those who completed the orientation phase of the program were more willing to engage in substance abuse treatment. Length of involvement in the day treatment center was associat- ed with reductions in substance abuse (McBride and VanderWaal 1997).

offender may be required to participate in treatment exercises to address reasons for relapse and may be required to submit to more frequent testing. If the offender contin- ues to test positive, he or she may be required to enroll in more intensive services (e.g., resi- dential treatment). Further, if an offender, who pleaded guilty and received a deferred jail or prison sentence so that he could enter treatment, continues to fail to comply with his treatment program, despite the imposition of intermediate sanctions, the ultimate sanction of a sentence of incarceration will be imposed. It is important, from a motivational standpoint, that other program participants see what will happen to them (i.e., incarcera- tion) if they fail to comply with their treat- ment programs.

Other sanctions such as victim impact meet- ings encourage the offender to recognize how drug-related activities affect the community. If the offender fails to complete the required treatment activities, victim restitution may be imposed as the next level of sanctions. By holding offenders accountable, graduated sanctions can be effective in redirecting indi- viduals away from substance abuse and toward recovery. In general, the availability and use of sanctions tends to strengthen the impact of treatment, just as involvement in treatment tends to strengthen adherence to community supervision arrangements.

Examples of sanctions used in diversion • Means-based fines (also called “day” fines).

The total amount of these fines is calibrated to both the severity of the crime and the discretionary income of the offender, with the calibration and calculation established by the court as a whole for all cases in which this type of fine is to be imposed. (This type of fine contrasts with traditional fines that are imposed at the discretion of the judge according to ranges set by the leg- islature for particular offenses.) Defendants with more income (and/or fewer family obli-

gations) pay a higher overall fine than those with lower incomes (and/or more obliga- tions) for the same crime. This approach to setting the fine amount is typically coupled with expanded payment options and collec- tion procedures that are tighter than usual.

• Community service. This is the performance by offenders of services or manual labor for government, private, or nonprofit organiza- tions for a set number of hours with no pay- ment. Community service can be arranged for individuals, case-by-case, or organized by corrections agencies as programs. For example, a group of offenders can serve as a work crew to clean highways or paint buildings.

• Restitution. Restitution is the payment by the offender of the costs of the victim’s loss- es or injuries and/or damages to the victim. In some cases, payment is made to a general victim compensation fund; in others, espe- cially where there is no identifiable victim, payment is made to the community as a whole (with the payment going to the munic- ipal or State treasury).

• Outpatient or residential substance abuse treatment centers. Both public and private treatment centers may be contracted to pro- vide treatment to offenders, as described in this TIP.

• Day reporting centers or residential centers for other types of treatment or training. These centers are established to provide services other than substance abuse treat- ment. For example, a center may provide skills training to enhance offenders’ employability. Offenders must report to the center for a certain number of hours each day, and/or report by phone throughout the day from a job or treatment site, as a means of monitoring.

• Intensive supervision probation. The level and types of supervision that are labeled intensive vary widely but usually involve closer supervision and greater reporting requirements than regular probation for offenders. This level can range from more than five contacts per week to fewer than

141Treatment Issues in Pretrial and Diversion Settings

four per month. Supervision usually entails other obligations (to attend school, have a job, participate in treatment, or the like).

• Intensive supervision parole has similar requirements and variations but is usually provided by parole agents to offenders who have completed a prison term and who are serving the balance of their sentences in the community.

• Curfews or house arrest (with or without electronic monitoring). Offenders are restricted to their homes for various dura- tions of time, ranging from all the time to all times except for work or treatment hours, with a few hours for recreation. Frequently, the curfew or house arrest is enforced by means of an electronic device worn by the offender, which can alert cor- rections officials to his or her unauthorized absence from the house.

• Halfway houses or work release centers. Offenders are restricted to the facility but can leave for work, school, or treatment. The facility is in the community or attached to a jail or similar institution.

• Brief jail incarceration (e.g., for 1–3 days). Brief incarceration is often used with offenders who have committed major pro- gram infractions in DTCs or in other diver- sion programs. This provides respite from temptations to use drugs and is useful in reinforcing the importance of sobriety and treatment. In some cases, incarceration can be used counterproductively for DTC or diversion participants if it is lengthy and if it prevents the offender from reengaging in treatment activities.

• Boot camps. Typically, a sentence to a boot camp (also called shock incarceration) is for a relatively short time (3 to 6 months). As the name implies, boot camps are charac- terized by intense regimentation, physical conditioning, manual labor, drill and cere- mony, and military-style obedience. Because boot camps are a form of incarcer- ation, some in the criminal justice field reject their inclusion in the category of intermediate sanctions. Others include boot

camps because placement in them is intend- ed to take the place of a longer, traditional prison term. Several research studies have shown that boot camps do not significantly reduce criminal recidivism or substance abuse. One potential explanation for these findings is that most boot camps do not pro- vide intensive substance abuse treatment services.

How to use sanctions Evidence on the usefulness of sanctions from other institutional settings demonstrates several principles.

• The efficacy of a punishment is determined, in large part, by the individual’s history and circumstances.

• Sanctions must be of sufficient intensity so the client does not become habituated to threats and punishments, yet not so severe that the judge exhausts all options for sanc- tions.

• A sanction should be delivered for each infraction.

• To the extent possible, sanctions should be delivered immediately after the undesirable behavior.

• Undesirable behavior must be reliably detected (e.g., through mandatory urinaly- sis two or three times per week).

• Sanctions must be predictable (by explicit statements of behavioral expectations) and controllable through the individual’s actions.

• Behavior does not change by punishment alone; desired behaviors should be reward- ed. Desired behaviors include those that are incompatible with drug use, those that are naturally rewarding, and those that are likely to be rewarded by the client’s social environment (Marlowe and Kirby 1999). Rewards for positive behavior and behavior change in DTCs include public praise and recognition of achievement by the judge and other staff, reduction of fees or time in the program, small prizes such as key chains or

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movie tickets, and certificates of phase and program completion.

Treatment Issues The counselor–client relationship in a pretrial setting raises unique challenges. For one, the role of the counselor can become blurred between therapist and gatekeeper, answerable to both the treatment and the criminal justice communities. In the midst of this role confu- sion, the client’s legal rights need to be careful- ly guarded.

The discussion below highlights some of the issues counselors operating in a pretrial setting are likely to face.

Importance of Screening Unpredictability characterizes the hours and days immediately following arrest. The rapid- ly developing nature of arrest and arraign- ment creates a challenge for counselors in gaining access to the arrestee. Arrests can occur at odd hours, while assessment staff are unavailable. Interviewing conditions, such as in a police lockup, are less than ideal. Still, the consensus panel believes that detainees should receive screening for substance abuse during the initial intake proce- dure to determine whether fur- ther assessment should be rec- ommended or whether referrals should be made. (See chapter 2, Screening and Assessment, for examples of appropriate screen- ing instruments.) Prompt screening is also important to identify offenders in need of detoxification services.

It is important for counselors to understand that offenders some- times sign up for treatment because “it’s the thing to do.” Accessing drug treatment can help an individual appear more sympathetic in the eyes of the court. Understanding this, some

offenders who do not genuinely have a drug or alcohol problem will participate in treat- ment nonetheless. One example is a drug dealer who does not have a substance use dis- order, but earns income from drug traffick- ing. During assessment the offender may deny using substances. However, once a clinician threatens to send the offender back to the judge, the offender may prudently decide he is boxed into “admitting addiction.” In this instance, the offender is simply using common sense to avoid harsher sentencing and improve his chances for leniency in the crimi- nal justice system.

To address this dilemma, the panel suggests that treatment counselors assess collateral evidence of a substance use disorder. Orientation and other “pretreatment” pro- gram components are also used to determine individual readiness and commitment to treatment, prior to involvement in more intensive program services. Not every offend- er is appropriate for treatment. For example, if a counselor assesses an individual who does not have a substance use disorder, the person should be referred back to the judge in order to avoid denying the offender’s due process rights, such as the right to a speedy trial. Early drug screening and the use of profes-

143Treatment Issues in Pretrial and Diversion Settings

Advice to the Counselor: Operating in a Pretrial Setting

• Counselors must maintain a client’s confidentiality. One strategy is to avoid discussing the client’s criminal case.

• Counselors should bear firmly in mind that the client is presumed innocent before trial.

• Counselors should be realistic about the responsibilities that a client is capable of handling in pretrial settings. For example, it is unrealistic to believe that a defendant will suddenly become a model citizen, meeting all of his or her responsibilities, simply because of an arrest.

• Counselors should avoid allowing individuals to be inad- vertently penalized for enrolling in treatment.

• Counselors should be aware that clients may be more focused on “beating the case” than on recovery.

sional alcohol breathalizers can also be help- ful in determining the need for further screening and treatment.

To better identify individuals with substance abuse problems and to provide informed diversion to treatment services, several jails have implemented a comprehensive screening, and use systematic “case finding” approaches (National GAINS Center 2000; Steadman et al. 1999). In some areas, TASC program staff perform these activities; in others, different types of “boundary spanners” perform these tasks. Generally, these are people who are knowledgeable about criminal justice process- ing and different community treatment sys- tems and resources.

Meeting Immediate Needs The pretrial setting can create difficult scheduling problems for clients. Individuals may have lost their jobs because of an arrest, and clients who are employed may wonder how they will hold onto their job if they are required to attend treatment. Counselors tend to believe that putting an individual into treatment is of primary importance during

this time period; however, they should be sen- sitive to the fact that although treatment is critically important, it is not always the client’s most pressing priority. This is espe- cially true when weighed against considera- tions such as displacement from housing and lack of appropriate childcare. Many clients who are navigating more immediate and pressing needs are not ready to engage in the therapeutic process. Effective triage helps to build client trust and lays a foundation for successful engagement in therapy.

The consensus panel recommends that coun- selors prioritize case management services to include the most pressing client needs, such as food, clothing, shelter, and medical treat- ment. Does the client need detoxification? Are there childcare issues to be resolved? Is the client in need of medication?

Maintaining Existing Services In many U.S. communities, individuals receiving Federal disability supports, such as Medicaid, Social Security Insurance, or Social Security Disability Insurance, often lose their benefits if they are detained in jail.

Although Federal regulations do not require these supports to be terminated for jail detainees, misunderstandings regarding policies often result in loss of services. Upon release, these individuals must re-apply for Federal supports, a somewhat lengthy process that often cre- ates a delay in access to commu- nity treatment services. A lapse between incarceration and treat- ment without benefits means that these individuals are often unable to meet their basic sub- sistence, health, and mental health needs and usually lose any stabilization gained while in jail, bringing them back in con- tact with the criminal justice sys- tem after a short period of time (National GAINS Center 1999b).

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Advice to the Counselor: Addressing the Client’s

Immediate Needs • Detoxification needs: Screen for the need for detoxifi-

cation services and refer clients when appropriate. Train staff in signs and symptoms of withdrawal so that staff can detoxify clients from alcohol and drugs.

• Childcare issues: Provide on-site childcare at treatment facilities.

• Potential forfeiture of public housing: Notify an indi- vidual’s landlord that the individual is receiving treat- ment.

• Transportation needs: Provide bus tokens, car-service vouchers, and transportation support.

• Medical needs: Ensure that medical needs are addressed, including receipt of prescription medicines and screening for infectious diseases.

Although Federal policies do not require an individual’s benefits to be terminated immedi- ately upon incarceration, they do stipulate a timeframe after which benefits cannot be received. Whether communities suspend or drop an individual’s Medicaid benefits depends on the State (National GAINS Center 1999b).

In Lane County, Oregon, diverted individuals with co-occurring mental and substance use disorders experienced difficulties in maintain- ing uninterrupted treatment due to issues with Medicaid and Social Security Insurance benefits. In response, the County raised its concerns with the Oregon Medical Assistance Program director. The State recognized this situation as a continuum-of-care issue for those with short-term stays in the jail. The State adopted the Interim Incarceration Disenrollment Policy, which states that indi- viduals cannot be disenrolled from the Oregon Health Plan during their first 14 days of incarceration (National GAINS Center 1999b).

In addition to this policy change, Lane County has coordinated with the local appli- cation processing agency for Medicaid and Social Security Insurance. This relationship allows detainees who did not have benefits upon booking or who have been incarcerated longer than 14 days to begin the application process while still in custody. Diversion pro- gram participants are now given priority and are able to regain or obtain benefits within a few days (National GAINS Center 1999b). The staff of the Lane County diversion pro- gram reports that the disenrollment policy has been crucial for offenders and has greatly benefited program participants. Other jail staff members, providers, and advocates are also encouraged to develop a thorough under- standing of the rules regarding Federal bene- fits, and to maintain an open line of commu- nication with the State Medicaid agency and local Social Security office (National GAINS Center 1999b).

Protecting Clients’ Rights The client’s due-process rights can affect the counselor’s role in the pretrial setting. Clients and counselors should not discuss the client’s ongoing criminal case. The boundaries of the counselor’s responsibilities can begin to blur when clients discuss their criminal cases. Counselors should avoid the situation of being forced to report to a prosecutor something they have been told concerning the client’s case.

A memorandum of understanding (MOU) can also protect a client’s rights. An MOU signed by the prosecutor will ensure that the prose- cuting attorney in the case will not use infor- mation gathered during the treatment process against the client. A judicial order attached to such an MOU may carry more weight: If the judge rules that information given to a treat- ment provider is out of bounds for a prosecu- tor, the client has that much more assurance that he or she may speak freely to the coun- selor.

Presumption of Innocence The issue of presumption of innocence points to an essential difference between the legal and therapeutic cultures. It also poses a chal- lenge for treatment counselors during the pre- trial phase. The dilemma is this: For individ- uals to participate in drug treatment, they must first admit to having a drug problem. As a result, when the crime is possession of drugs, counselors often have a more difficult time presuming a client’s innocence.

“Presuming their innocence never occurs to me. I’m usually trying to convince the clients they have a problem.”

—Counselor

Coercive Power of Treatment Staff The impact of arrest itself carries trauma, uncertainty, and disruption that are different from being in jail. This uncertainty can either help or hinder counselors who are trying to

145Treatment Issues in Pretrial and Diversion Settings

engage clients in treatment. The aftermath of the arrest often provides additional motiva- tional leverage and counselors can better engage their clients in treatment by assessing this motivation. Are they seeking to avoid prosecution? Do they want to remain in the community? Counselors who perceive clients’ motivation and assist them in meeting short- term goals provide strong incentive to engage them in the treatment process. For coun- selors, the keys to meeting these short-term goals are awareness of resources and the abil- ity to offer them.

Counselors working in the pretrial setting have additional leverage with clients in that they are responsible for making recommenda- tions to the court concerning adherence to and progress in treatment. However, the counselor’s role is potentially more adversari- al. Self-disclosure to a counselor is not neces- sarily in the client’s best interest. As a result, it may be more difficult to engage the client in an open relationship. The counselor should inform the client at the outset that at some point it may be necessary to report to the court or pretrial supervision staff. The coun- selor should be absolutely clear about this process, its requirements, and his or her role in relation to the community supervision agency. In some settings, such as drug courts, counselors are part of a multidisciplinary team and play a vital role in case reviews and determining clients’ disposition. For example, counselors provide regular and periodic reports regarding client treatment adherence and progress. The judge may defer to the counselor’s opinion regarding recommenda- tions for the client’s promotion to different phases, or graduation from the program, giv- ing the counselor additional leverage in moti- vating clients to engage in treatment.

Checks and Balances on a Counselor’s Influence The power of the counselor in pretrial and diversion settings raises several important ethical questions. Should counselors be able

to circumvent a client’s release conditions? What assurance is provided that counselors will act with fairness and consistency? What measures can be taken to prevent counselors from abusing this power? Should some type of oversight mechanism be established to avoid the potential abuse of power? These types of checks and balances are incorporated within drug treatment courts. For example, team staff meetings provide a forum for discussion to review each case prior to court hearings and to achieve consensus regarding what the judicial and drug court program response will be to infractions or other critical incidents.

Developing Pretrial Treatment Services Efforts to expand and institutionalize treat- ment programs in order to make them a stan- dard part of the pretrial criminal justice sys- tem often face a number of challenges. In planning such programs, the consensus panel believes the following strategies may be help- ful:

• Increase the number of experienced coun- selors and trained clinical staff.

• Create special licensing and certification for counselors who provide treatment in the pre- trial setting.

• Increase awareness of the importance of the pretrial setting in promoting clients’ suc- cessful recovery.

• Educate the media concerning the effective- ness, usefulness, and importance of provid- ing treatment in pretrial and diversionary settings.

• Demonstrate that the services provided are effective in reducing substance abuse and recidivism.

• Expand treatment options to include brief interventions and treatment readiness programs.

• Consider the effects of treatment on case processing.

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• Include stakeholders from a variety of domains in the planning process.

Effective Pretrial and Diversion Programs The consensus panel recommends that to be effective in providing substance abuse treat- ment, diversion programs need adequate staff resources, training, and coordination, along with program components adapted to crimi- nal justice settings. These recommended ele- ments are discussed in detail below.

Staff resources Staff for effective programs can include both counseling personnel and individuals in liai- son and administrative roles. Counselors can provide information regarding how to access treatment services and available treatment programs. A liaison resource coordinator can disseminate this information, or an adminis- trator can maintain a database of treatment programs, supervise referrals, and provide coordination between treatment and the

court. As “boundary spanning” staff mem- bers, they can perform the delicate balance between social work, social justice, and social control.

To ensure that trained personnel are avail- able to deliver services on a timely basis, pro- grams could hire additional staff or link to other treatment programs and agencies. For example, treatment providers may not have the ability to offer anger management or liter- acy training classes in a particular program site. Given the cost of maintaining these spe- cialists, agencies could provide these services through contract vendors. Clinical agencies may also need to contract for backup staff in order to reduce the size of caseloads and to provide 24-hour services for offenders who are arrested and/or processed during “off hours.”

Training Cross-disciplinary training for effective pro- grams emphasizes the importance of sub- stance abuse interventions and criminal jus- tice supervision while making available the

147Treatment Issues in Pretrial and Diversion Settings

Baltimore’s Response to Drugs and Crime

Since the early 1990s, Baltimore, Maryland’s substance abuse prevention and treatment agency, the Board of Directors of Baltimore Substance Abuse Systems, Inc. (BSAS), has faced a crime rate that is double the national average, an increase in the spread of infectious diseases, and economic costs of drug use exceeding $2.5 billion a year. Baltimore’s drug problem is among the worst in the Nation. At least 60,000 Baltimore city residents need alcohol and drug treatment (Smart Steps 2000).

In its efforts to tie high-quality, readily available treatment to comprehensive wraparound services, BSAS recognizes that outside help is crucial, given the strict limitations on Baltimore’s own budget. To aid in this effort, neighborhoods across the city have come together to form a Crime and Drugs Solution Work Group, whose major goal is to improve the quality and quantity of drug treatment. Another orga- nization, the Greater Baltimore Interfaith Clergy Alliance, which represents over 200 congregations in the region, is working to strengthen community-based treatment services in neighborhoods throughout the city. Over the past several years, The Baltimore Sun, the city’s major newspaper, has editorialized frequently to raise awareness of the need to boost the city’s investment in drug treatment. Other local organizations and foundations have advocated more public funding for treatment, and have even con- tributed their own dollars (Smart Steps 2000).

For more information on Baltimore’s commitment and approach to improving drug treatment, go to www.drugstrategies.org/Baltimore.

information that all staff members need. CSAT has provided technical assistance to States seeking to establish cross-training pro- grams. While early efforts focused on training probation officers and treatment staff, more recent training activities have focused on cre- ating multidisciplinary teams of staff from different systems that collaborate to engage and retain offenders in treatment. The Addiction Technology Transfer Centers (ATTCs), funded by CSAT, also offer an extensive array of training and resource materials for use by criminal justice and treatment professionals. For more informa- tion, contact the ATTC National Office at (816) 482-1200, or their Web site at www.nattc.org.

Effective substance abuse treatment is cultur- ally competent. That is, the programs and staff demonstrate behaviors, attitudes, and policies that enable them to work effectively in cross-cultural situations (Cross 1989). Cultural competence is based on understand- ing and respect for differences among people and groups. It is important to recognize that culture plays a complex role in people’s lives and in the development of substance abuse problems and their treatment. Cross-training is an appropriate time to review practical examples of cultural competence in program development and operation. Staff require training in cultural diversity and issues spe-

cific to the cultural populations that they serve. (See the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development b].)

The consensus panel suggests that judges, too, must stay informed about issues in many areas. Organizations such as the American Bar Association, the National Judicial College, the National Association of State Court Judges, the American Judicature Society, and the National Association of State Judicial Educators ensure that judges receive many kinds of information and training.

Coordination Effective programs include mechanisms for coordination and information exchange between substance abuse and criminal justice agencies (including MOUs, discussed below). For example, individuals need to be screened for diversion, and their treatment histories given; diversion programs often require that specific conditions be met. Both situations entail communication between agencies if the defendant is to receive appropriate treat- ment.

In addition, the pretrial environment requires coordination in making key clinical decisions, including determination of the treatment intensity, duration, modality, set-

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Suggestions for Improving the Timing of Treatment

Effective programs work to optimize the timing and sequencing of treatment services. The following approaches can be helpful:

• Provide screening and assessment at the earliest possible point in the justice system.

• Move offenders into treatment as soon as possible.

• Provide several levels of care, including detoxification.

• Develop flexible sanctions so clients who have been unable to access treatment are not punished for this.

• Provide services to increase the offender’s motivation to engage in treatment.

• Address the offenders’ denial.

• Use brief interventions, where appropriate.

• Identify treatment and ancillary resources in the community.

ting, and specific services required. Counselors can work with the court to devel- op consensus-building approaches to deal with these critical issues that arise during the course of treatment, with the goal of develop- ing mechanisms to advise judges regarding the best course of action for an individual’s treat- ment. Decisions regarding diversion to treat- ment that provide a balanced consideration of public safety needs are complex when offend- ers have multiple cases in different courts, including noncriminal systems (e.g., family court, housing court, child welfare cases). Some offenders are already on probation, parole, or other types of supervision when they are arrested. The challenge is then to determine and arrange a hierarchy of services within multiple systems (e.g., criminal justice, treatment, child welfare).

Successful interagency cooperation requires information sharing that is coordinated as quickly as possible. Establishing commonly accepted protocols, such as those required for sharing information, is also useful in promot- ing this coordination. (For information on confidentiality, go to www.hipaa.samhsa.gov and see CSAT 2004.) Case managers who pro- vide wraparound services and work within both the treatment and justice systems are also instrumental in improving interagency coordination and can address critical issues such as insurance coverage and navigating through managed care networks.

Memorandums of Understanding MOUs are useful for clarifying who has responsibility for various decisions related to sanctions, treatment, and case disposition, and under what conditions these decisions can be modified. Effective programs set up MOUs to establish guidelines and procedures for treating the client, sharing information, and maintaining the confidentiality of infor- mation. First, MOUs foster cooperative inter- agency relationships by ensuring that each component of the treatment system is aware

of how the other components will access, share, and use information (Tauber et al. 1999). Second, when participants sign the consent to disclosure (permitting the coun- selor to share information from the client’s treatment), the MOU can be used to explain how information will be distributed to the criminal justice system. (See also www.hipaa.samhsa.gov and CSAT 2004.) The following are the consensus panel’s recom- mendations for elements that should be con- tained in MOUs.

• MOUs typically note that discussions at team meetings are confidential, in part because of legal concerns but also to promote trust and fairness.

• If outsiders are permitted to attend treat- ment team meetings, the MOU should require them to sign an agreement that they adhere to the confidentiality provisions of the law (redisclosure) and the MOU.

• MOUs should state that the prosecutor’s office will not use information obtained in the drug treatment to prosecute the partici- pant, with two exceptions: child neglect or abuse and crimes committed at the treat- ment center or against treatment personnel. A prosecutor frequently learns of offenses by participants, particularly drug posses- sion offenses. In some cases, an offender who commits a crime may lose eligibility for the drug court program (among other possi- ble consequences) but should not be prose- cuted for crimes based on information that was acquired during the drug court pro- ceedings.

• The MOU should describe the conditions under which the information can be shared or held confidential.

• The MOU should encourage the free flow of information within the drug court team to promote the drug court’s mission.

• The MOU should include rules governing the storage of, and the access to, written and electronic records. Federal law requires such written policies (Tauber et al. 1999).

149Treatment Issues in Pretrial and Diversion Settings

Procedures To Serve the Best Interests of the Offender Even at the pretrial stage, the best interests of the offender may be seen differently by the substance abuse treatment and criminal justice systems. While the former strives to assist offenders in recovery, the emphasis in the crim- inal justice system is to prevent further illegal actions and ensure compliance with court orders and conditions. A common goal of both programs is to prevent recidivism.

A central challenge for treatment in the crimi- nal justice setting is determining who has jurisdiction over program violations. Offenders may not know the “rules” or the exact consequences of their actions. Clients may fail to complete obligations in the crimi- nal justice system without violating treatment requirements. The question becomes: Should clinicians report this violation if it could adversely affect the individual’s treatment? Does the discretion of the clinician undermine the sanctity of the judicial system? Other con- cerns include the format of a clinician’s report: If a violation occurs, should the report be in a regular general format or an immediate communication?

Sanctions, as well as incentives to engage in treatment, should be described in clear writ- ten guidelines. This information should be provided to clients in the presence of their attorneys in order to make certain they understand the sanctions. These guidelines should be grounded in reality. For example, jailing an employed individual can be poten- tially excessive punishment. The sanctions should be fair, consistent, and involve each of the agencies. Education and cross-training are needed for both criminal justice and treatment professionals in order to ensure

that sanctions are provided in a fair, consis- tent, and timely manner.

How can a public defender convince a client that treatment might be best if it goes against the client’s legal interests? The role of the counselor is to engage the client in treat- ment—but the role of the attorney is to advo- cate the wisest legal course. The attorney’s role becomes more complicated when the need for treatment is identified. Legal counsel tra- ditionally plays the role of gatekeeper, although negotiating treatment issues in the pretrial setting can call for a different role. Defense counselors need specific training in what can and cannot be achieved in treat- ment, and the advantages and potential risks related to the clients’ enrollment in treat- ment.

The use of drug testing in the pretrial setting is somewhat controversial. It is argued that because drug use is associated with criminal behavior, those currently using drugs are more likely to commit additional crimes if they are released into the community while awaiting trial, and that these individuals are less likely to appear for trial if they continue to use drugs. Belenko and colleagues (1992) report that drug testing does not appear to be a cost-effective method for predicting which defendants are at risk for pretrial miscon- duct. Their examination of pretrial drug test- ing at six sites showed that the testing did not consistently predict pretrial misconduct bet- ter than other information available at the time (e.g., prior arrest record, indications of ties to the community).

Belenko and colleagues (1992) make several additional arguments against pretrial drug testing for detainees in the absence of treat- ment. First, one could argue that judges

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The Paradox of Diversion, Treatment, and Public Safety

Diversionary treatment is perceived as a threat to public safety because offenders are quickly placed back into the community. However, over the long run, diversionary treatment increases public safety because individuals involved in substance abuse treatment are less likely to commit crimes (Belenko 2001).

would be more likely to release detainees if they required periodic drug testing because this condition of release would act as a system for monitoring their behavior. In fact, this has not happened. Second, staff costs and costs for purchasing drug-testing equipment are substantial. Third, the accuracy of drug testing technology is not perfect. False-posi- tive results can have serious consequences for a defendant, and given the number of drug tests an offender is required to take over the course of 6 months, the chances of receiving at least one false-positive result can be signifi- cant. Finally, mandatory drug testing raises constitutional issues of due process, self- incrimination, and unnecessary search and seizure.

Pretrial drug testing is considered a search under the Fourth Amendment to the U.S. Constitution. Court rulings have determined that it complies with due process when collec- tion and testing procedures meet the legal test of reasonableness (Bureau of Justice Assistance 1999). From the treatment per- spective, however, part of the difficulty with drug testing is that it can only flag the pres- ence or absence of certain drugs. It cannot discriminate between chronic and casual users—between those with a substance use disorder who would benefit from treatment and those who are experimenters.

Drug testing alone does not provide enough information to make decisions about pretrial release or detention or referral for treatment. Rather, these results should be combined with other information available in the pretrial setting or from a thorough clinical assess- ment. Drug testing is, however, a necessary and useful adjunct for monitoring offenders’ compliance with conditions. As an intermedi- ate sanction, drug testing often decreases drug use among offenders. Although drug testing and sanctions alone are limited in what they can provide, there are some indi- viduals who will stop using drugs if they are tested.

Many clinicians believe that offenders who have not been able to access drug treatment should not be punished for testing positive. Nonetheless, use of drug testing alone without sanctions is sometimes used as an alternative to treatment and may lead to an individual’s exclusion from treatment. The Washington, D.C., Drug Court provides drug testing and sanctions without drug treatment. This com- bination of sanctions without treatment is referred to as the “Coerced Abstinence Model.” The D.C. Drug Court does demon- strate reduced recidivism, though the impact on drug use is unclear (Belenko 1990).

Resources

Examples of Diversion Programs These programs, in the view of the consensus panel, exemplify effective diversion programs. While some are still in operation in 2005, oth- ers are not.

Brooklyn Drug Treatment Alternative to Prison (DTAP) Program The Brooklyn Drug Treatment Alternative to Prison program was established by Kings County District Attorney Charles J. Hynes in 1990 to divert nonviolent felony offenders with one or more prior felony convictions and a documented history of drug abuse into treatment. Although DTAP started as a deferred prosecution model, in 1998 the DTAP shifted to a deferred sentencing model (Kings County District Attorney’s Office 2001).

DTAP’s target population includes nonviolent felons who, under New York State’s Second- Felony Offender Law, face a mandatory prison sentence. Defendants accepted into DTAP have their sentences deferred while undergoing 15–24 months of rigorous, inten- sive drug treatment. Those who successfully

151Treatment Issues in Pretrial and Diversion Settings

complete treatment are returned to court to have their charges dismissed. The program is a therapeutic community with a rigid struc- ture, rules, timetables, and goals. As of March 2005, 2,094 individuals have begun the program, 831 have completed it, and 374 are currently enrolled (Kings County District Attorney’s Office 2001).

A 5-year study of the program indicates that 53 percent of these participants have complet- ed it (National Center on Addiction and Substance Abuse [CASA] 2003). Their re- arrest rates and reconviction rates are signifi- cantly lower than a matched sample of offenders who received regular processing in the criminal justice system. After 2 years, DTAP graduates were 87 percent less likely to return to prison. In addition, preliminary results show that graduates had decreased their drug use compared with offenders who dropped out of the program or did not partic- ipate. Those participating in DTAP stayed in treatment longer than those in the general treatment population (17.8 months, compared to 3 months). Retention rates were highly associated with high levels of perceived legal pressure to remain in treatment. The average cost for a person in DTAP compared favor- ably with costs of incarceration: $32,975 ver- sus $64,338 (CASA 2003).

Memphis Prebooking Jail Diversion Program Memphis police officers have been specially trained to handle mental health and substance abuse crises while on patrol. They receive training in psychiatric diagnosis, substance abuse issues, de-escalation techniques, commu- nity mental health and substance abuse resources, and legal issues. The officers have a working relationship with the University of Tennessee’s Medical Center and help communi- ty agencies implement treatment plans for those diverted to treatment.

Montgomery County (Pennsylvania) Pre- and Post- Booking and Coterminous Jail Diversion The county’s Emergency Services works closely with County Administration and a local Task Force to maximize multidisciplinary involve- ment in the diversion program. Its success is credited to police training, a 24-hour crisis response team, inpatient treatment, case man- agers, and an outreach team. Prebooking uses psychiatric treatment in lieu of arrest while postbooking involves regular screenings for incarcerated individuals with mental health and substance abuse problems. By taking an offender directly to psychiatric treatment while concurrently filing charges, police engage coter- minous jail diversion, which diverts the indi- vidual from criminal incarceration. The pro- gram was funded through a CSAT grant to the University of Pennsylvania.

Addiction Prevention and Recovery Administration and the Salvation Army These two organizations have formed a part- nership to expand the current community- based residential treatment program, Salvation Army Beacon for Adult Males in the Justice System, through a grant awarded by the U.S. Department of Health and Human Services. The program, which was funded through a CSAT grant to the District of Columbia’s Department of Health Addiction Prevention and Recovery, addresses the needs of men in pretrial or presentence status who abuse substances and who have been charged with a nonviolent drug-related crime. The program currently serves 95 men annual- ly, but the grant will increase the number by 30 and incorporate Treatment Readiness and an aftercare component.

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Assistance for drug treat- ment courts The National Association of Drug Court Professionals (NADCP) is the main member organization that provides advocacy and sup- port for the development of drug treatment courts throughout the country. The group has an extensive training and technical assistance program with experience in planning and implementing drug courts and establishing community linkages with law enforcement. A network of 27 mentor drug courts uses practi- tioners to act as resources at meetings and conferences and onsite visits. (For more information, see the NADCP Web site at www.nadcp.org/index.html.)

Other pretrial diversion models • Phoenix, Arizona’s and Eugene, Oregon’s

Substance Abuse and Mental Health Services Administration (SAMHSA) Diversion Projects (for co-occurring disorders)

• Jacksonville, Florida, Drug Court (pays for aftercare)

• Pensacola, Florida, Drug Court (serves as “mentor” court for other drug treatment courts)

• San Bernardino, California, Drug Court (higher level of supervision and services pro- vided for the most serious offenders)

• Reno, Nevada, Family Drug Court (one of the earliest family/dependency drug courts)

• South Carolina’s statewide diversion program

• Various sites participating in the SAMHSA Jail Diversion project

Program Resources The following resources include instructional as well as financial assistance.

Substance Abuse and Mental Health Services Administration To help States break the pattern of incarcera- tion without treatment and reduce the high rate of recidivism, SAMHSA provides grants for diversion and reentry programs for adoles- cents, teens, and adults with substance use and mental disorders. These grant programs focus on treatment as well as housing, vocational and employment services, and long-term supports. For more information go to www.samhsa.gov.

Bureau of Justice Assistance (BJA) The BJA in the U.S. Department of Justice is authorized by Congress under the Edward Byrne Memorial State and Local Law Enforcement Assistance Program to make grants to States in order to improve the func- tioning of the local criminal justice sys- tem. The program places emphasis on violent crimes and serious offenders, and the enforcement of State and local laws that establish offenses similar to those in the Federal Controlled Substances Act. The Drug Court Grant Program in the BJA administers financial and technical assistance and training to State, local, and tribal governments and jurisdic- tions to develop and implement drug treat- ment courts. (Additional information is avail- able at www.ojp.usdoj.gov/BJA.)

153Treatment Issues in Pretrial and Diversion Settings

SAMHSA

provides grants

for diversion and

reentry programs

for adolescents,

teens, and adults

with substance use

and mental

disorders.

Training outlets • National Association of Pretrial Services

Agencies (www.napsa.org/)

• National TASC Conference (for case man- agers, assessment staff, clinicians) (www.nationaltasc.org/)

• National Drug Court Institute (provides tar- geted training for all of disciplines involved in drug courts; judges, prosecutors, defense attorneys, probation officers, treatment pro- fessionals) (www.ndci.org/aboutndci.htm)

• National Association of Drug Court Professionals Annual Training Conference (www.nadcp.org/home.html)

• The National GAINS Center (www.gainscenter.samhsa.gov/html/ default.asp)

Conclusions and Recommendations The consensus panel highlights the conclusions and recommendations as follows:

• The vast majority of offenders processed through the criminal justice system during the pretrial phase have chronic substance abuse problems, as well as high rates of vocational, social service, educational, men- tal, and physical health needs.

• The rapid movement of offenders through different points of processing in the crimi- nal justice system complicates delivery of substance abuse treatment services and pre- sents challenges in sharing information and encouraging continuity of involvement in treatment.

• Pretrial services programs face many chal- lenges in identifying and referring offenders in need of treatment. These include provid- ing timely clinical assessment, timely refer- rals to services, effective monitoring of treatment progress, referral, and case man- agement.

• Pretrial drug testing is unlikely to be more effective than indicators such as the prior arrest record and family or other communi-

ty ties in predicting pretrial misconduct (Belenko et al. 1992).

• Treatment providers face several challenges in serving pretrial clients. These include developing processes to transfer informa- tion between jails, courts, community supervision, and treatment agencies, and strategies to identify and resolve potential conflicts between courts, supervision, and treatment staff related to clinical decision- making, sanctions, and level of supervision.

• Access to effective treatment and other ser- vices is sometimes limited for offenders at the pretrial stage.

• Diversion from prosecution and treatment can occur at several points in the criminal justice process and can result in a variety of case dispositions (Anglin et al. 1999; Broner et al. 2002).

• There is a significant need for cross-training of criminal justice and treatment staff, use of culturally sensitive treatment approach- es, and for stakeholder involvement in pro- gram planning in pretrial and diversion set- tings.

• Community task forces provide an impor- tant mechanism to coordinate activities of various community agencies that are involved in diversion programs.

• To capitalize on the initial and sometimes fleeting interest in personal and lifestyle change that can accompany arrest, individ- uals in pretrial settings should be screened as soon as possible for substance use disor- ders, detoxification needs, and other imme- diate needs.

• Mental health screening and assessment should be conducted as soon as possible after consideration for diversion programs, and when appropriate, clients with mental disorders should be referred to specialized programs that are tailored to address their needs.

• Treatment in pretrial and diversion settings should focus on immediate needs, such as housing, transportation, economic support,

154 Chapter 7

and vocational placement and training. Counselors should consider use of brief interventions that are based on early identi- fication of substance abuse treatment and other urgent needs.

• Drug courts and other diversion programs hold considerable promise for engaging and retaining offenders who have substance use disorders and for reducing substance abuse and criminal recidivism during periods of program participation and following pro- gram completion.

• Providing access to continuing involvement in community recovery services is essential to maximize the long-term impact of pretri- al and diversion programs.

• Diversion programs for those with co-occur- ring disorders are most effective when they provide integrated treatment for mental dis- orders and substance use disorders (Broner et al. 2002).

• Few studies have examined treatment ser- vices in pretrial and diversionary settings. Further research could help identify and reduce gaps in services, identify beneficial services, inform clinicians regarding useful and effective changes, evaluate program effectiveness, and assist in providing pro- gram funding.

• More research is needed to determine the economic costs and benefits of treatment interventions at the pretrial stage. Intensive and long-term programs that target first- time or low-risk offenders are not likely to be cost-effective. At the same time, limited nonintensive interventions for chronic seri- ous offenders are also unlikely to be cost- effective.

155Treatment Issues in Pretrial and Diversion Settings

157

8 Treatment Issues Specific to Jails

In This Chapter…

Definitions

Trends

Treatment Services in Jails

Description of the Population

Key Issues Related to Treatment

What Treatment Services Can Reasonably Be Provided in a Jail

Setting?

Coordination of Jail Treatment Services

Examples of Jail Treatment Programs

Research Related to Jail Treatment

Recommendations for Treatment Providers

Overview This chapter addresses treatment options that can be provided for jail inmates with substance use disorders who are incarcerated for relative- ly short periods of time. This chapter discusses treatment issues specific to jails through an examination of what constitutes a jail, who is incar- cerated in jail, how and when substance abuse treatment can be provid- ed, and what types of treatment are effective in this setting. Recommendations are made regarding the treatment services that can be provided within the physical, legal, and policy confines of a jail; and, finally, the treatment interventions that are best suited for brief, short- term, and long-term periods of jail treatment. This is followed by an overview of the larger systems that affect treatment in a jail setting. Lastly, the chapter outlines the research, provides examples of existing programs, and makes recommendations for the treatment of substance abuse in jails and detention centers. It should be noted that this chapter addresses diversion only as it relates to the jail population. For more information on diversion, see chapter 7.

Definitions Jails (also called detention centers) house diverse groups of people detained for a wide variety of reasons. Jails confine people during the adjudication process (i.e., arraignment, criminal court, grand jury, hearings, trial, sentencing). These individuals are referred to as detainees and have not yet been sentenced. Jails also confine those sen- tenced to short-term incarceration (usually 1 year or less) and serve as a holding facility for

• Individuals who have allegedly violated probation, parole, or bail condi- tions

• Those who are absconding from court-ordered programs or other com- munity placements

• Juveniles who are awaiting transfer to juvenile authorities or adult State prisons

• Inmates awaiting transfer to State, Federal, or other local authorities

• Inmates transferred from overcrowded Federal, State, or other prisons

• Individuals detained by the military

• Those held for protective custody

• People punished for contempt

• Witnesses detained by the court

• People with mental illness pending transfer to appropriate mental health facilities (Harlow 1998)

The approximately 3,365 jails in the United States (Stephan 2001) range in size from small jails located in rural areas to large jails typical- ly located in or near large urban areas. The sociodynamics of jails vary according to size. For example, inmates housed in jails that serve rural communities often are familiar with other

inmates, while those incarcerated in large, complex systems have less chance of being housed with someone they know.

Trends Several recent trends have led to changes in the jail population. Enactment of harsher sentencing laws for drug offenses has led to increases in the number of minority and female inmates. At the same time, significant- ly reduced funding for the mental health care system has led to an increase in the number of multiproblem inmates (National GAINS Center 2002; Peters 1993; Peters et al. 1997).

As a result of these changes, jails house grow- ing numbers of individuals who have been displaced from traditional societal “safety nets” such as State hospitals. By necessity, jails have enlarged the scope of their mission

158 Chapter 8

Defining a Jail

For the purposes of the Jail Manager Certification Program only, the American Jail Association defines a jail as

1. A county, municipal, or regional facility(ies) that houses pretrial and sentenced inmates and/or an institution that houses pretrial and sentenced inmates where the State is responsible for jail opera- tion(s) (e.g., Alaska, Connecticut, Delaware, Hawaii, Rhode Island, Vermont); and/or a private facil- ity that houses pretrial and sentenced inmates and exists to serve the local jail needs of the communi- ty in which it operates.

AND/OR

2. A facility that houses only pretrial detainees, regardless of what entity operates it. This includes, but is not limited to, facilities that house people for less than 72 hours (lockups); facilities that house Federal or military custody inmates awaiting trial (e.g., the Immigration and Naturalization Services, U.S. Marshals, Armed Forces); institutions where the State is responsible for the operations of jails, and private facilities.

AND/OR

3. A local government or private facility that houses convicted people who, without this facility’s exis- tence, would serve their sentence in the local jurisdiction’s jail (e.g., Milwaukee County House of Correction).

A facility is not a jail if its purpose is to house sentenced inmates

1. Who are, or who would be under normal circumstances, incarcerated in a State institution

2. Who are, or who would be under normal circumstances, incarcerated in a Federal institution

These institutions include State prisons, Federal prisons, Texas State Jails, State work camps, and State boot camps.

to serve as community “gatekeepers” in iden- tifying and addressing a range of psychosocial problems, such as HIV/AIDS, domestic vio- lence, educational deficits, homelessness, mental illness, and, increasingly, substance use disorders (Peters and Matthews 2002).

Substance use disorders among the jail popu- lation have risen since the 1980s. In 1989, 67 percent of jail inmates had committed a drug offense or used drugs regularly. By May 1998, that number had increased to 70 percent— approximately 7 in 10 jail inmates. An esti- mated 16 percent committed their offense to obtain money for drugs (Wilson 2000). Increases in jail substance abuse treatment programs have not kept up with this trend (Belenko and Peugh 1998; Peters and Matthews 2002). In recent years, however, levels of substance use and abuse seem to have stabilized or even decreased slightly depending on the substance in question. In 2002, 66 percent of jail inmates reported reg- ular alcohol use (down from 66.3 percent in 1996) and 68.7 percent reported regular illicit drug use (up from 64.2 percent in 1996), with regular use defined as use at least once a week for a month or more (James 2004).

Jails often serve as the first opportunity for offenders to have their substance use disorder and other problems (e.g., other mental disor- ders) identified, to have their acute needs sta- bilized (e.g., detoxification from alcohol or opioids), and to receive referrals to in-house or community services (Peters and Matthews 2002). In fact, many offenders’ initiation into treatment is in jail (Mumola 1999). Thus, the challenge to jail administrators is two-fold: to recognize the need for treatment and to understand that treatment must vary based on the population (e.g., by culture, average length of stay, type of crimes, psychosocial needs).

Treatment Services in Jails Findings from several studies indicate the effectiveness of in-jail substance abuse treat- ment programs in reducing criminal recidi- vism (Peters and Matthews 2002). Reductions in rearrests for treated inmates range from 5 percent to 25 percent in comparison to untreated inmates, over followup periods of 6 months to 5 years. Treated inmates also have a longer duration to rearrest following release from incarceration, relative to untreated inmates. Other positive outcomes associated with in-jail treatment include reduced rates of relapse among treatment participants (Tucker 1998), lower levels of depression (San Francisco County Sheriff’s Office Department 1996), and fewer disciplinary infractions (Tunis et al. 1997). Cost savings associated with jail treatment programs have been reported from $156,000 to $1.4 million per year (Center for Substance Abuse Research 1992; Hughey and Klemke 1996).

Despite the positive outcomes associated with in-jail treatment, two-thirds of jails do not offer treatment (excluding such ancillary ser- vices as assessment, self-help groups, and educational programming) (Substance Abuse and Mental Health Services Administration [SAMHSA] 2000). About two-thirds have self- help programs and about 30 percent have detoxification programs. Of jail inmates who reported ever having used drugs, only one in eight had participated in any treatment (even broadly defined) since their admission, and most of those reported were self-help pro- grams (Wilson 2000).

Description of the Population At midyear 2003, local jails held or super- vised 762,672 people, of whom approximately 10 percent (71,371) were outside the jail facil- ity (e.g., under electronic monitoring, in out- side treatment programs, on work release, etc.); this figure represented a 3.9 percent

159Treatment Issues Specific to Jails

increase over the number of inmates held in jail at midyear 2002. Between 1995 and 2003 the number of jail inmates per 100,000 resi- dents increased from 193 to 238, an increase of over 23 percent. More than half of the adult jail inmates (60.6 percent) were not yet convicted of the crime for which they were being held (Harrison and Karberg 2004). According to a 1999 survey of jail inmates, 5 percent were known to be noncitizens (Stephan 2001).

Crimes Crimes committed, or allegedly committed, by jail inmates are fairly evenly divided between violent offenses (24.4 percent), property offenses (24.4 percent), drug offenses (24.7 percent) and public-order offenses (24.9 per- cent). The most common offenses are drug trafficking (12.1 percent), assault (11.7 per- cent) and drug possession (10.8 percent) (James 2004). Compared to other jail inmates, offenders driving while intoxicated are older, better educated, and more likely to be Caucasian and male (Maruschak 1999a).

Income and Education According to 2002 data, approximately 44 percent of jail inmates had not received a GED or graduated from high school. Twenty- nine percent of jail inmates were not working at all at the time of their arrest and only 57.4 percent were employed fulltime. Jail inmates also reported low incomes, with 59 percent reporting monthly incomes of less than $1,000 (James 2004).

Gender Between midyear 1995 and midyear 2003, the percentage of male inmates dropped from 89.8 percent to 88.1 percent, while the per- centage of female inmates rose from 10.2 to 11.9 percent. This means that as of 2003 men were per capita eight times more likely than women to be in a jail. During the year prior to June 30, 2003, the number of female

inmates in jail rose 6.3 percent while the number of male inmates increased by 3.7 per- cent (Harrison and Karberg 2004).

Over 55 percent of jailed women report phys- ical or sexual abuse prior to admission, with 44.9 percent reporting physical abuse and 35.9 percent reporting sexual abuse (James 2004). Women are also more likely to be iden- tified as having mental illness. Approximately 22.7 percent of female inmates and 15.6 per- cent of male inmates were identified as having mental illness (Ditton 1999). A survey of inmates in State prisons and jails indicated that men with mental illness were twice as likely as other men to report a history of abuse (Ditton 1999).

Offenses vary by gender. For example, women were more likely to be held for drug possession than trafficking, whereas the reverse was true for men; women were also more likely to be held for property offenses than violent offenses, and again the reverse was true for men. However, a greater per- centage of women in jail are there for drug offenses. The common offenses for which women in jails were being held in 2002 were drug possession (14.5 percent), fraud (14 per- cent), drug trafficking (10.9 percent), and larceny/theft (10.3 percent). For men, the most common offenses were drug trafficking (12.3 percent), assault (12.2 percent), drug possession (10.3 percent), and burglary (7.2 percent) (James 2004).

Race and Ethnicity As of midyear 2003, the largest proportion of jail inmates were Caucasian (43.6 percent) or African American (39.2 percent). African Americans were 5 times more likely than Caucasians and 3 times more likely than Hispanics/Latinos to be in jail (Harrison and Karberg 2004). Caucasian jail inmates report- ed higher rates of mental illness (21.7 per- cent) than either African Americans (13.7 percent) or Hispanics/Latinos (11.1 percent) (Ditton 1999). Among convicted jail inmates, Caucasians were more likely to be using alco-

160 Chapter 8

hol (38.5 percent) and/or illicit drugs (33.2 percent) at the time of their offense than African Americans (29.3 percent and 27.3 percent respectively) or Hispanics/Latinos (30.1 percent and 23.8 percent respectively) (James 2004).

Substance Abuse A history of drug use is a common character- istic of the jail population, although patterns of use have changed somewhat in recent years. Compared to jail inmates in 1996, inmates in 2002 reported more use of mari- juana, depressants, stimulants (other than cocaine), and hallucinogens in the month prior to the offense and less use of cocaine and heroin/opioids. As noted earlier, in 2002, 66 percent of jail inmates reported regular alcohol use and 68.7 percent reported regular illicit drug use. Approximately 35 percent of all convicted males and 31 percent of females reported that they had been drinking alcohol when they committed their offenses (James 2004). Of convicted jail inmates who were actively involved with drugs, 72 percent were on criminal justice status at the time of their arrest (i.e., were on probation or parole, had pretrial status, were out on bail, or had escaped) (Wilson 2000).

The percentage of those who participate in substance abuse treatment programs in jails varies widely. The average population is young, male, and, like the general jail popu- lation, fairly evenly distributed between African Americans (42 percent) and Caucasians (39 percent). The majority of par- ticipants (58 percent) are ordered to treat- ment programs as a condition of their sen- tence, and most have prior felony convictions (Peters and Matthews 2002). The percentage of jail inmates who used alcohol or other drugs regularly participating in some type of substance abuse treatment (including self- help group participation) after arrest has increased from 12.3 percent in 1996 to 15.1 percent in 2002 (James 2004). Among inmates jailed for driving while intoxicated (DWI) offenses, only 17 percent are involved in pro-

grams such as self-help and educational groups for alcohol abuse, compared with 62 percent of probationers who receive these ser- vices. Only 4 percent of those jailed for DWI receive any type of alcohol abuse treatment including detoxification or counseling (Maruschak 1999a).

HIV Status At midyear 2002, 1.3 percent of jail inmates who reported their test results were known to be HIV positive (Maruschak 2004), rates far in excess of those within the general popula- tion (Centers for Disease Control and Prevention 2004a). Between 1998 and 1999, AIDS-related deaths accounted for 8.5 percent of all deaths in jails mak- ing it the third lead- ing cause of death in jails (death by natu- ral causes was the leading cause of death, followed by suicide) (Maruschak 2001). However, the number of AIDS- related deaths in jails decreased from 9 per 100,000 inmates in 2000 to 6 per 100,000 in 2002 (Maruschak 2004).

In 2002, 3 percent of African-American women, 2.9 percent of Hispanic/Latino inmates (both male and female), 1.6 percent of Caucasian women, 1 percent of African- American men, and .6 percent of Caucasian men reported testing positive for HIV. African-American men, however, made up the largest number (163,219) of HIV-positive jail inmates (Maruschak 2004).

161Treatment Issues Specific to Jails

The percentage of

those who partici-

pate in substance

abuse treatment

programs in jails

varies widely.

Co-Occurring Mental Disorders In 1998, an estimated 16 percent of jail inmates reported either a mental disorder or an overnight stay in a mental hospital. Mental illness was most commonly reported by offenders between the ages of 45 and 54, with 23 percent identified as mentally ill (Ditton

1999). Many people with mental illness cycle through jails repeatedly. Individuals with mental illness are admitted to jails at approximately eight times the rate at which they are admitted to public psychiatric hospi- tals. As a result, there are more peo- ple with severe men- tal illness in U.S. jails than in State hospitals (Torrey et al. 1992). A review of administrative data for jail detainees and inmates in New

York City found that approximately 15,000 people with mental health problems cycle through that correctional system and back into the community each year, of which a sig- nificant portion have co-occurring disorders (Lamon et al. 2002). The Urban Justice Center, a New York City advocacy group, reported that detainees and inmates with mental illness spend significantly more time incarcerated—an average of 215 days versus 42 days—when compared to those not identi- fied as mentally ill (Winerip 1999). One study found that homelessness is strongly associated with mental illness among jail inmates: half of the ever-homeless sample of inmates in the New York City correctional system responded positively to at least one mental illness screen- ing question (Michaels et al. 1992). Of those, many, if not most, are repeat offenders.

According to the research collected and reported by the National GAINS Center (2002), 6.4 percent of male and 12.2 percent of female jail detainees have severe mental ill- ness. Among male detainees at intake, 2.7 percent meet the criteria for schizophrenia/ schizophreniform disorder, 1.4 percent for mania, and 3.9 percent for major depres- sions. Among female detainees, 2.0 percent meet the criteria for schizophrenia/ schizophreniform disorder, 1.4 percent for mania, and 10.5 percent for major depres- sion. Twenty-nine percent of male and 53 per- cent of female jail detainees have a substance use disorder, and both male and female detainees have a 72 percent rate of both men- tal illness and substance use disorders (National GAINS Center 2002). Inmates with both disorders are significantly more likely to have multiple problems in terms of employ- ment, family relations, and health, and are at greater risk for not complying with treatment, rearrest, homelessness, violence, and suicidal behavior when compared to those without this combination of disorders (Borum et al. 1997; Peters et al. 1992; RachBeisel et al. 1999; Steadman et al. 1998; Swartz and Lurigio 1999). In a study of 204 pretrial jail detainees in substance abuse treatment in a Chicago jail, more than half met the lifetime criteria for at least one mental disorder, and the life- time rates of serious mental illness were high- er than those reported in the general jail pop- ulation. Individuals with co-occurring disor- ders were also more likely to have been arrested for property offenses; to be depen- dent on alcohol, marijuana, or PCP; and to have more than one psychiatric disorder. Moreover, the study revealed a correlation between severe mental illness, antisocial per- sonality disorder, and drug abuse (Swartz and Lurigio 1999).

162 Chapter 8

Jails can serve a

pivotal role in

engaging family

members, peers,

and community

organizations in

supporting the

recovery efforts of

inmates.

Key Issues Related to Treatment Several factors affect the availability and effectiveness of treatment in jails. It has been the experience of consensus panel members that treatment, if available at all, may not be offered to those in need because the methods for screening and selecting treatment partici- pants may not be comprehensive. For some inmates, the length of jail stay may be too short for substance abuse interventions. Others, especially those in pretrial status, may decline to participate. Even when ser- vices are available, they are not always responsive to the inmates’ psychological, social, medical, and mental health needs, and some inmates have special needs that are too complex to be addressed fully in brief or short-term treatment.

This section addresses factors unique to jails that the consensus panel believes can impact the availability and/or effectiveness of treat- ment. See chapter 5 for more general issues affecting treatment.

Public Perceptions About Jails Although jails are designed to improve public safety and to provide punishment through the short-term detention of defendants and con- victed inmates, they are sometimes perceived negatively by the public. A negative percep- tion can affect the morale and attitudes of jail staff, particularly relating to treatment ser- vices. The community may not realize that jails hold a significant number of individuals who are arrested for low-level, nonviolent charges; that many offenses committed by jail inmates are related to their substance abuse and/or mental health problems; and that most will return to their community within a short amount of time.

Through their work with local community agencies, treatment staff can assist in dis- pelling misperceptions and increase the sense of inclusion of the jail as part of the commu- nity’s network of services. Because of their

involvement with individuals who often cycle through a variety of community services and agencies, jails are ideally situated to develop partnerships to improve community services. Many jails have worked to establish “beach- heads” to develop healthcare services, pre- vention and education programs, and voca- tional services, particularly for “high-risk” groups such as the homeless, those with HIV/AIDS, and inmates with co-occurring mental disorders. Jails can serve a pivotal role in engaging family members, peers, and community organizations in supporting sub- stance abuse treatment and the recovery efforts of inmates who are enrolled in treat- ment services. Jails can also help facilitate partnerships between community groups and local corrections for the purpose of identify- ing, treating, and referring (through diver- sion or aftercare) inmates with substance use disorders, and reinforce the concept that “treatment works.”

Time Constraints One of the most serious challenges for sub- stance abuse treatment in jails is the small amount of time available, both in terms of scheduling treatment and in terms of the duration of jail incarceration (Leukefeld and Tims 1992). Many pretrial inmates are housed in jail for only short periods of time. Time constraints are a particularly significant factor given that research shows a correlation between treatment effectiveness and length of time spent in treatment (Swartz et al. 1996).

A jail must operate on a schedule that includes periods of time during which inmates are locked-in for inmate count for meals or other structured activities (e.g., work). Thus, despite the importance of time spent in treat- ment, programs must compete for the inmate’s time. Some jails offer evening pro- gramming, but this is sometimes difficult to arrange and substantially increases staffing costs. Due to scheduling constraints within jails, an inmate may have to decide between enrolling in a treatment or an educational program.

163Treatment Issues Specific to Jails

Also, offenders are confined to the jail for limited, and often uncertain, lengths of time. This is particularly true for unsentenced, pretrial inmates who may be released from jail unpredictably following a court hearing. Ideally, treatment programming can be devel- oped according to a modular structure that accommodates differing time lengths and goals—from initial engagement and education to developing skills and completing steps.

Environmental Issues A large number of people enter jails both as visitors and as service providers. While reach-in from the community and visits from family should not be discouraged, coordinat- ing and overseeing such activities is time con- suming for staff who may need to spend time processing and escorting visitors that could otherwise be spent with clients. Treatment providers who visit clients from outside the institution may also find a significant portion of their time on the premises taken up with waiting and processing.

Jails also maintain a classification-based sys- tem that is typically based on security needs and bed/space availability, and which may or may not coincide with an inmate’s treatment needs. Many small, rural, or older jails in particular have environments and structures that are not conducive to treatment: They were built to detain, house, and process inmates, and not to provide screening, assess- ment, or treatment services. There may not

be individual interview or treatment space available, and group treatment space may also be scarce. If activity space is available, educational, work, religious, and treatment programs often compete for this space, and the amount of treatment programming is often compromised. Architecturally, jail activity rooms and housing units are not soundproof. Noise can provide distraction from treatment activities and can be a source of stress for both clients and treatment providers.

Finding space that is private and that pro- vides security for both staff and inmates is a challenge. While corrections and treatment staff may find joint solutions, informing clients of these limitations is important. The counselor should also be aware of the limita- tions this may create for discussing certain issues or engaging particular populations (e.g., detainees with certain charges, certain trauma events, severe mental illness), or even for conducting a thorough assessment. Privacy is also hampered by the fact that an inmate is never alone; there is electronic surveillance in jails as well as security person- nel and other inmates.

Gang Affiliation The counselor should be aware of the jail’s policies and programs regarding gang affilia- tion, including rules regarding who should participate in certain groups and activities or which actions may lead to an administrative

164 Chapter 8

Suggestions for Dedicated Program Space

The effectiveness of substance abuse treatment services would be significantly enhanced by dedicated pro- gram space in jails that is isolated from general housing units. Dedicated staff office space would optimally be provided in an area within or adjacent to the isolated treatment unit. The benefits of providing dedicated treatment space include the following:

• Privacy in conducting treatment and staff meetings

• Reduced competition for treatment program space

• More readily available staff

• Reduction of issues related to inmate movement and coordination

or new criminal charge during detention. Knowledge of the gangs in the jail may allow the counselor to foresee which activ- ities could be used to inflame rival gangs, to set clear group rules for activities, and to clear- ly define the counselor’s role of balancing security and facility rules with good treatment prac- tices, thereby avoiding sending mixed messages to the inmate or placing him- or herself at odds with correc- tions.

Stress Related to Incarceration A number of issues beyond the individual’s readiness for treatment can affect his engage- ment in the treatment process within a jail setting. Many of the stressors identified in chapter 5 are present in jails, including trau- ma related to the recent arrest, uncertainty of the legal situation, and possible loss of a job or custody of children. Counselors are in a position to assist the client in developing cop- ing mechanisms to address substance abuse issues within the context of multiple internal and external stressors, to clarify which issues can be addressed while incarcerated within the bounds of certain timeframes, and to make referrals to other jail or community ser- vices to address non–substance-abuse-related issues and to facilitate continuity of treatment from jail into the community (e.g., legal and medical problems, education, vocational training or work programs, diversion or aftercare programs). See chapter 7 for a more detailed discussion of interpersonal issues fac- ing recent arrestees.

Issues Related to Justice System Processing and Legal Representation The legal process can understandably confuse detainees, and either this disorientation can persist for a lengthy period (e.g., during adjournments, plea bargaining, competency

processes, or diversion planning), or the sta- tus of the case can rapidly shift and the detainee may be suddenly released from jail. Often there is little communication between the court, jail staff, and treatment staff, which has direct impact on the therapeutic relationship, as the detainee’s legal status is a major concern.

Defense attorneys do not always visit clients while they are in jail, with brief visits often occurring at court prior to the stressful and sometimes confusing court proceedings. Further, for those detainees who reach out to peers for support, information is often inac- curate and can increase their sense of urgen- cy and hopelessness. Due to the wide variety of populations incarcerated in jails, detainees may learn about scenarios that are not rele- vant to their own case processes.

Attorneys do not always recognize the bene- fits of treatment and may not encourage the inmate’s involvement in treatment. For exam- ple, due to heavy caseloads, many public defenders do not take the time to advise clients about how treatment could benefit them. In some jurisdictions, the appointed defense counsel may not be from the public defender’s office and may not be aware of diversionary or other treatment options. Despite the presence of substance abuse prob- lems, defense counsel may in some cases be reluctant to advise their client to voluntarily submit to treatment due to conditions of supervision that are likely to lead to sanctions and incarceration. The flow of information between legal and treatment professionals can also be problematic, related to the types of

165Treatment Issues Specific to Jails

Advice to the Counselor: Jailed Clients

• Counselors should be aware of gang affiliations as well as the jail’s policy regarding who should participate in certain groups. This knowledge may allow the counselor to foresee which activities could be used to inflame gang rivalries, set clear group rules for activities, and balance security with good treatment practices.

information that counselors can provide to their clients’ attorneys, whether counselors can testify in court, and the types of legal information that the treatment provider needs for purposes of counseling.

Confidentiality Substance abuse treatment programs should establish clear guidelines regarding the type of information that may be disclosed after an offender has signed a proper consent form. The Federal confidentiality laws and regula- tions protect any information about an offender if the offender has applied for or received any substance abuse-related services from a program covered by the law. Programs included are those that specialize, in whole or in part, in providing treatment, counseling, and/or assessment and referral services for offenders with alcohol or other drug problems. A different confidentiality issue can arise in small, rural jails, where inmates and officers often know each other. Residents with substance use disorders are well known, and it is difficult to keep confi- dential the fact that someone is receiving treatment. For more information about the confidentiality laws and regulations and their implications for substance abuse treatment in jails, see CSAT 2004 and go to www.hipaa.samhsa.gov.

Counselor–Client Issues Given the complexity of the environment and issues needing to be addressed, it is useful for the counselor to clearly describe his role and limitations related to that role, the structure of the proposed treatment, and the various options available. For instance, the counselor should explain whether he or she will become involved in legal, family, medical, disci- plinary, or other issues. The counselor should describe the potential treatment options, how these options may or may not impact the client’s problems, and what other types of treatment or interventions may be needed to address the client’s problems that are not

offered within a jail setting. While the client’s reactions to this information may initially vary from rage to indifference to relief, offer- ing ways to cope with limitations and stressors is more useful than initially placating the client. The counselor should be aware of the protections and limits to protections that informed consent may have. (For more infor- mation on confidentiality, go to www.hipaa.samhsa.gov and see CSAT 2004.)

Supervision and training Supervision and ongoing participation in training are essential for jail treatment coun- selors, given the complexity of issues, present- ing symptoms, and behaviors related to the inmate population, and the limitations to the physical structure and environment of the jail. Supervision can support the counselor and help clarify the different systems’ demands, potential personal reactions to these demands, and personal reactions to the clients themselves. These clarifications help determine when these issues should be part of or separate from the treatment and which issues should be addressed systemically. Support and continued professional develop- ment can reduce therapist burnout and increase treatment efficacy.

What Treatment Services Can Reasonably Be Provided in a Jail Setting? There have been several efforts to develop guidelines for jail-based treatment programs that describe model treatment approaches and minimum standards of care. For exam- ple, the Office for Treatment Improvement (now the Center for Substance Abuse Treatment [CSAT]) convened a “Criminal Justice Treatment Evaluation Meeting” in 1992 to identify critical elements of jail-based substance abuse treatment programs and jail

166 Chapter 8

treatment guidelines (SAMHSA 1996). There is still a need, however, for more specific guidelines that can be operationalized by local jails. The American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC) have standards related to jails, but they are extremely limited in the area of sub- stance use, and far less specific and detailed than those developed for mental health ser- vices in jail. No specific guidelines have been adopted for substance abuse treatment in jail, nor do existing standards account for the elaborate contextual and environmental fac- tors affecting treatment in jail settings.

There is currently no single prototype for jail substance abuse treatment programs, but rather a range of available programs that vary in content and intensity according to the inmates’ length of stay (Leukefeld and Tims 1992; Peters and Matthews 2002). Some detainees are in jail less than a week, during which they may receive only assessment and referral, whereas others are serving a sen- tence in a jail setting. Several different dura- tions of treatment are discussed in this section to examine the range of treatment options that might be provided in jail. In this section the panel recommends a framework by which to identify priority treatment services, given a defined period of time available to provide treatment services for inmates. For purposes of this section, “brief” treatment is defined as up to 30 days, “short-term” treatment is defined as from 1 to 3 months, and “long- term” treatment is defined as 3 months and longer. Regardless of the duration of treat- ment, however, the goal should always be to engage clients so that treatment and recovery can continue when they leave jail. Issues of screening and assessment, regardless of the setting, are discussed in chapter 2.

Treatment intensity and duration are increased with length of stay, as is the scope of topics that can be addressed. More inten- sive treatment services are often necessary, given that the substance abusing lifestyle has taken years to develop and cannot be altered

in just a few weeks. Figure 8-1 (p. 168) out- lines optimal treatment components that might be deployed at each level, followed by a more detailed explanation of each. Each suc- cessive level of treatment in this layered approach includes service components from previous levels.

Regardless of the duration of treatment, com- plicating factors for those in jail include co- occurring medical problems and histories of physical and sexual abuse, unstable relation- ships and social support structures, poverty, homelessness, gender, and cultural differ- ences, among others. Combinations of factors can interact differently with any of these subpopula- tions, have implica- tions for treatment strategies, and have an impact on treat- ment outcomes. Consequently, when designing or adapt- ing treatment pro- grams, it is impor- tant to factor in these variables along with the substance choice patterns of use and types of pre- vious treatment and services.

Level I: Brief Treatment Some offenders may be identified within a short period of jail detention for involvement in community diversion programs that include participation in treatment. For many other inmates who are incarcerated 30 days or less, case management, referral, and brief interven- tions can be provided. Brief treatment usually focuses on supplying information and making referrals.

167Treatment Issues Specific to Jails

Support and

continued

professional

development can

reduce therapist

burnout and

increase treatment

efficacy.

Motivational enhancement therapy and motivational interviewing Motivational enhancement approaches help clients to address their ambivalence about involvement in substance abuse treatment, and to identify methods of dealing with this ambivalence. (For more information about motivational interviewing, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999b].) The goal of this process is to engage inmates in a discussion of the treatment process and their potential reasons for changing substance abuse behavior and to help inmates develop their own rationale for changing this behav- ior. This approach is designed to help coun- selors work with clients who are ambivalent

about treatment, in denial about their cir- cumstances, and resistant to change.

In Project MATCH, the largest clinical trial ever conducted to compare different alcohol treatment approaches, a four-session motiva- tional enhancement therapy yielded long-term overall outcomes that were similar to those of other, more intensive outpatient methods. Further, the results of this study strongly sug- gested that motivational interviewing could be applied across cultural and economic groups.

Enhancing detainees’ motivation for change and increasing their receptivity to substance abuse treatment can be effective in this set- ting as well. For example, materials devel- oped at Texas Christian University (TCU) include a board game called Downward Spiral, which helps clients examine the conse-

168 Chapter 8

Figure 8-1 Treatment Components

Brief Short Term Long Term

Level I (1 to 4 weeks)

Level II (4 to 12 weeks)

Level III (3 months or more)

Motivational interviewing

Relapse prevention Communication skills Employment counseling

Orientation to treat- ment/treatment plan- ning, and substance abuse education

12-Step programs Dealing with domestic vio- lence

Therapeutic community

Information on available community resources

Basic cognitive skills Anger management Family mapping and social networks

Following through on 12 steps

Facilitating access to community services

Identity and culture Problem solving Continued stabilization

Community linkage and transition services

Strengths building Social skills training Cultural factors

Psychotropic medica- tions: education and compliance

Criminal thinking

quences of substance abuse. Other useful exercises include the Decision Matrix, which looks at advantages and disadvantages of con- tinued substance use from the client’s per- spective and at the benefits of choosing to dis- continue use. This helps identify functional aspects of their substance use (e.g., socializa- tion, reduction of negative emotions) that sus- tain patterns of use, and that may serve as barriers to continued abstinence and involve- ment in treatment.

Substance abuse education Because inmates may not have examined the negative health consequences related to sub- stance abuse, an educational component can inform and possibly change risky behaviors. Films, presentations, and literature can be used to present this education. The ultimate goal of treatment is abstinence, but people who have abused substances long-term have had difficulty successfully addressing issues such as boredom, anxiety, social discomfort, and being ostracized by family and peers.

Information on available community resources Community resource information ranges from how to obtain a restraining order to what community organizations offer substance abuse treatment. Counselors in the pretrial setting need to be aware of their community’s resources in order to assist their clients after release. Many of these individuals will be

released back to the community with their numerous needs unchanged and/or unmet. Clients can be referred to Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) groups, and counselors can provide help with finding job training programs, general educational programs, clothing, food, and public assistance. Before this information is presented to inmates, however, counselors must check to see that an agency will accept referrals from the criminal justice system, and assess eligibility criteria. Some programs have developed resource directories with descriptions of community services programs and relevant contact information.

Facilitating access to community services Incentives can be established for substance abuse treatment staff to enter jails to work with inmates enrolled in treatment. One step is to develop contract language that identifies jail inmates as a priority group to receive publicly funded substance abuse treatment services. Another is to establish funding for health benefits. In New York City, for exam- ple, an inmate’s Medicaid eligibility in a com- munity program can be reinstated while the inmate is still in jail so the paperwork is ready when that inmate is released; a similar system has also been developed for establish- ing temporary Medicaid coverage. Some com- munity organizations may be less resistant to taking on former inmates as clients if these individuals are receiving Medicaid support. Once a health problem or mental illness is

169Treatment Issues Specific to Jails

A Voice of Experience

I believe that jail administrators have an obligation to provide the programs by which inmates can better themselves, and this includes alcohol and drug abuse programs. But in South Carolina—and only in South Carolina—anyone sentenced to more than 90 days, with the exception of family court, goes to State prison. The rest come here. Consequently, with this small average length of stay, it’s very difficult to justify the sig- nificant commitment of resources that are needed with such a revolving door atmosphere.

—Mark F. Fitzgibbons, CJM Director, Buford County (SC) Detention Center

identified, Medicaid may be needed in order to cover treatment in the community for those affected.

Community linkage and transition services Offenders who abuse substances are perhaps at their most vulnerable when they are mak- ing the transition back to the community. The treatment system needs to plan for an inmate or detainee who is leaving the jail, and the community needs to be prepared to receive the individual. Case managers or other types of “boundary spanner” staff are particularly trained to manage these transitions. They are cross-trained in issues related to the mental health, substance abuse, and criminal justice systems, and will help to facilitate aftercare or diversion (Steadman et al. 1995; Taxman 1998) (see also TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community [CSAT 1998b]).

These staff members can handle multiple tasks—from being advocates to understand- ing the available community resources and linking exiting inmates to those resources. The most common types of linkage and transi- tion services provided by jail substance abuse treatment programs are assessment of after- care needs, discharge planning, placement planning, and coordination with community treatment agencies (Peters and Matthews 2002). Jail aftercare coordinators or treat- ment counselors, community resource coordi-

nators, or case managers often provide these services. Specialized reintegration programs are often helpful in developing postrelease plans related to housing, aftercare, relapse prevention, and employment.

While the goal of treatment is to help an inmate to abstain from substance use, the reality is that inmates are at high risk for relapse and in some cases overdose upon their release from jail. Overdose prevention efforts prior to release can prevent deaths, especially for inmates who have been off the streets for a period of time. Counselors should provide inmates with information about the decreased tolerance that results from abstinence.

Psychotropic and other medications: Education and adherence Many inmates will benefit from education regarding psychoactive medications, how they work, the reason for certain medication schedules, flexibility in dosage, side effects and how to manage these, and the relation- ship between mental and substance use disor- ders and noncompliance with medications and decreased efficacy of medications. Clients should understand the distinction between psychotropic medication and substances of abuse but also be informed about which medi- cations can be addictive. This type of educa- tion also provides a venue for discussing the relationship of mental disorder symptoms and the potential sense of stigma associated with

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A Voice of Experience

Since 1993, the Clark County (NV) Drug Court’s 1,725 graduates have experienced only a 17 percent recidi- vism rate—as compared with the 80 percent recidivism rate of people addicted to drugs who are released from jails or prisons. According to our drug court judge, this is the best method so far to treat people addicted to drugs. I agree. To have an impact on substance abuse in the jail population, an approach of long-term, high-quality treatment with community follow-up is the answer.

—Captain Marilyn Rogan Clark County (NV) Detention Center

mental health problems and ongoing medica- tion regimens.

For a significant number of inmates with a history of opioid abuse, review of existing opi- oid substitution medications will also be quite useful, including methadone, levo-alpha- acetyl-methadol, buprenorphine, and other medications used in detoxification from or reduction of opioid use. There has not been widespread use of these medications in jails, primarily because they are seen as potential sources of contraband, prolonging physical dependence on opioids, and requiring special- ized medical supervision.

Level II: Short-Term Treatment Level II, short-term treatment (approximately 4–12 weeks in duration) enables greater depth of involvement in the treatment process. Short- term treatment is built upon the previously described basic Level I services. Level II or short-term treatment interventions provide more focus on coping skills to prevent sub- stance use and sustain recovery.

Substance cravings, urges, and relapse prevention Inmates learn about actions that can trigger their substance cravings and how cravings

and urges are tied into relapse prevention. They can also complete exercises to identify personal “substance use triggers” and review strategies for avoiding and dealing with these triggers. For example, group discussion may focus on what inmates may expect when returning to their families, who may not fully support their involvement in recovery. While support from non–substance-using family members can be an enormous contribution to help the client stay clean and sober after release, reunification with family members is often accompanied by stress related to the family’s distrust and anger over the offend- er’s past substance use, unresolved conflicts with the partner or spouse, shifting parental roles, and added financial obligations (Peters 1993). Returning to live with family members who actively use substances or who condone substance use within the home creates addi- tional high-risk situations for the offender. In some cases, return to the home environment can trigger a relapse. Counselors should assess the home situation and possibly exam- ine alternative housing arrangements. Counselors may instruct clients that certain areas of town (e.g., drug neighborhoods) are “no-fly” zones and that they will be violating conditions of their treatment program and/or supervision if they frequent those parts of town.

171Treatment Issues Specific to Jails

A Voice of Experience

I am a psychologist working in a jail. We learned that our policy of stopping methadone “cold turkey” resulted in a very high frequency of booking recidivist inmates on drug charges related to heroin. So, work- ing with our County Executive, we stopped withdrawing and stopped the practice of “stopping” on Sundays. Now, if someone comes in, they continue, and we encourage agencies to send their case manager into the jail and make plans for the inmate’s release, so there is no gap ... What we’ve noticed is—we have very, very few bookings of individuals who were taking methadone. But we haven’t reached the point of initiating methadone treatment—that would be our next step. And I think that would be a great idea, because every- body is so happy with what we’ve been doing.

—Lawrence W. Smith, Ph.D. Psychiatric Services Administrator

King County (WA) Department of Adult and Juvenile Detention

Self-help programs Level II treatment is an opportunity for inmates to learn about self-help programs and their availability in the community. While not typically considered substance abuse treat- ment, such groups as NA and AA provide a valuable and accessible source of peer sup- port for inmates returning to the community.

In the past several years, new case law has found that AA and NA are essentially reli- gious-based treatment programs (Griffin v. Coughlin 1996; Kerr v. Farrey 1996; Warner v. Orange County 1999). While many States continue to sentence offenders to AA or NA, in at least one State (New York), the court has found that doing so is a violation of the first amendment. Authorities may be able to resolve this issue, however, by either remov- ing these coercive requirements or by incor- porating nonreligious alternatives (Cohen 2000).

Some jails offer alternative types of peer sup- port groups, such as SMART Recovery, which is based on cognitive–behavioral prin- ciples of Rational Emotive Behavioral Therapy. While licensed professionals in the community sometimes organize such groups, it is individuals in recovery who lead them.

Basic cognitive skills Cognitive skills training helps inmates correct thoughts that can lead to criminal behavior and substance abuse. These interventions help inmates understand the relationship between thoughts, emotions, and behaviors, and strategies to address maladaptive thought processes that can lead to interpersonal con- flict, emotional disturbance, and aggressive and violent behavior. Cognitive skills learned in jail treatment programs are often general- izable to other settings, including work, school, and relationships with significant oth- ers and family members.

Strengths building Strengths building identifies and uses the assets that clients bring to the treatment pro- gram to improve their chances for successful recovery. Counselors can examine interactive ways for participants to recognize their strengths, for example, by having inmates write something positive about each group member, then by identifying characteristics of themselves they think are good, and consider- ing how they can build on those strengths in the future.

Researchers at TCU have developed a series of readiness and induction interventions that incorporate a strengths-building strategy (Dees et al. 2000). These interventions give participants unique opportunities to define their roles in treatment and to discover their positive personal strengths and hidden cogni- tive potentials. In Tower of Strengths inter- vention, for example, participants examine their strengths and those they most wish to have. These activities are suitable for use in custody or community settings, and can be used in groups of up to 35 participants or in individual counseling.

The TCU readiness and induction interven- tions were designed specifically to overcome problems often encountered in working with those mandated to treatment. They address the distorted and negative expectations about treatment common among clients in criminal justice programs, and their lack of self-confi- dence resulting from personal failures, educa- tional and vocational deficiencies, and poor coping skills.

Communication skills This type of intervention can improve inter- personal skills and increase assertiveness with key family members, significant others, and individuals at work. Key activities often address effective means of expressing anger and other negative emotions, dealing with conflict situations, and dealing with problems

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that arise in personal relationships, whether at work or in the home.

Anger management These activities can help inmates recognize when they feel angry, identify some of the causes of their anger, and learn to use alter- native problemsolving techniques to help manage their anger. These interventions are also helpful in understanding the connection between anger and substance abuse, given that poorly managed anger often precipitates substance abuse.

Domestic violence In these cases, short-term strategies are developed to maintain personal safety for vic- tims of domestic violence and protect chil- dren, and longer term solutions are consid- ered that involve legal and law enforcement action. Having staff who are aware of avail- able community shelter and domestic abuse counseling services is also helpful.

Problemsolving These skills allow people to address and solve their own everyday problems in a rational manner by defining those problems and examining potential solutions. Inmates can begin by talking about problems they have encountered in the past, how they tried to solve them, and whether their efforts succeed- ed or failed. Then they can examine problems they have solved in a positive manner. Inmates learn how to select a solution ratio- nally, instead of emotionally or acting out immediately. This requires that they learn how to take time to look at a problem, weigh the advantages of alternate solutions, and anticipate their effects.

Discussions involving real incidents of prob- lemsolving can help inmates articulate meth- ods of problemsolving that typically produce success. For example, a client might describe an argument with his employer, and how he or she intentionally arrived 15 minutes late to

work the next day. If that individual’s response did not improve the situation, others in the group might indicate what they would do when faced with a similar situation: “I would avoid the situation,” “I’d try to ignore him,” “When he asked me something, I’d get defensive.” The purpose of this exercise is to identify effective ways to proceed. An effec- tive response that could result in desirable responses and outcomes might be, “I went in to ask my boss if I could speak with him for a minute, apologized, gave him the reason for the tardiness, and made a commitment not to have this happen again.” This approach is most effective when coun- selors make use of real-life issues, role- playing, and group interaction.

Social skills training Social skills training can be provided independently or as part of modules related to problem- solving and anger management. This training can help inmates deal appropriately with coworkers, family members, and friends. The process includes acquiring and rehearsing drug-free and prosocial skills to deal with interpersonal problems faced during recov- ery. Key components include communication skills, assertiveness, skills for developing and sustaining interpersonal relationships, and specific drug coping skills to handle high-risk interpersonal situations. Other areas include conflict management and learning interper- sonal skills related to work, family, and com- munity settings.

173Treatment Issues Specific to Jails

Strengths building

identifies and uses

the assets that

clients bring to the

treatment

program to

improve their

chances for

successful

recovery.

Level III: Long-Term Treatment When inmates are incarcerated more than 90 days, more treatment time is available to build on the tools provided in short-term treatment and aid the inmate in the transition back to the community. Level III or long-term treatment approaches include components similar to those found in residential treatment in many community-based programs. These interventions are designed to delve more deeply into personal values, belief systems, and issues related to cultural and family background that have supported a substance abuse lifestyle.

Employment counseling Employment counseling, which can examine an inmate’s employment skills and include skills testing, can be incorporated into work release or furlough. Counselors should pro- vide pre-employment training (e.g., communi- cation skills with employers, responsibility, punctuality) and résumé writing. To elicit information to strengthen their résumés, clin- icians can ask such questions as what have clients done as a volunteer, community mem- ber, or in jail that contributes to their employment opportunities rather than consid- ering only traditional work experience. Counselors can help their clients develop action plans for obtaining employment after release.

Building a therapeutic community Limited duration therapeutic communities have been established in some jail programs. For a more complete discussion of therapeutic communities, see chapter 9, Issues Specific to Treatment in Prisons.

Family mapping and social networks Family mapping is a structured approach to examine the family network and background. The purpose is to look at the family and try to understand its criminal and/or substance use history and how the family adapted over the years in an effort to maintain stability. The inmate looks beyond his or her immedi- ate family to grandparents, aunts, and uncles because many criminal and substance-using behaviors run in families and move across generations. This close examination helps people understand how and why substance abuse and other maladaptive behaviors exist in their family.

Female inmates, in particular, remain part of their community even while in jail and contin- ue to establish social relationships and main- tain social supports. However, while in jail they encounter significant problems in main- taining family contact and support, such as having their children searched for contra-

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A Voice of Experience

Long-term actions, started in jails, which include voluntary acceptance of behavior altering elements, can be effective. They must include abusive substance abstinence, the unburdening of the conscience, and the concept of continuity of care. Treatment must have a solid aftercare component that provides social, family, and community lifestyle changes that encompass jobs as well as education. It must also include daily rein- forcement of positive behavior and a new look at life, itself, from a healthy attitude, to be successful. When those actions encompass such a program, success of the individual is possible and productive life skills can be achieved.

—Tim Ryan Santa Clara County (CA) Department of Correction

President-Elect, American Jail Association

band, limits on visitation, glass barriers between mother and child, and having staff members monitor the visits, which often have a negative impact on family relationships. For some issues related to the family, it is impor- tant to have the family present.

There are innovative jail programs that work with the inmate and child welfare agency to create specific visit times for father or moth- er, caseworker, and child in order to stream- line visit procedures for agencies (City of New York 2001). Such models may be able to be used for other types of family meetings.

Co-occurring disorders Longer term treatment provides the opportu- nity for learning about the interrelated nature of substance abuse and mental disor- ders, including events leading up to relapse of mental disorders, such as discontinuation of psychiatric medication. Other key interven- tions include psychiatric consultation to review medications, education regarding men- tal disorders, and development of transition plans for followup mental health and sub- stance abuse services in the community. Treatment of individuals with co-occurring substance use disorders and mental illness is discussed in greater detail in chapter 5.

Criminal thinking Many inmates have developed ingrained pat- terns of thinking that contribute to poor

interpersonal relationships and lead to con- flict with others and involvement in criminal behavior. Inmates frequently do not see the connection between their criminal behavior and these patterns of thinking or belief sys- tems. By identifying and challenging mal- adaptive criminal thinking patterns such as generalizations, absolutes, exaggerations, and lies, offenders can become more critical in their thinking and question the thoughts that lead to their criminal behaviors. A number of structured curricula have been developed for this purpose that blend cognitive and behav- ioral approaches that are consonant with other skills approaches used in jail-based substance abuse treatment programs. For more information on criminal thinking, see chapter 5.

Coordination of Jail Treatment Services The consensus panel believes that in order to operate a successful jail drug treatment pro- gram, cooperation is needed between funding sources, the community, substance abuse counselors, criminal justice personnel, out- side agencies, and the offender, among oth- ers. This section is based on the experiences of consensus panel members and highlights some of the potential barriers involved in coordinating jail treatment services, then dis- cusses a number of possible solutions to bar- riers that are frequently encountered while implementing these services.

175Treatment Issues Specific to Jails

A Voice of Experience

Both short-term and long-term substance abuse treatment programs in jails are most effective when accom- panied by aftercare within the community upon release. Inmates will readily volunteer to participate in treatment programs within the confines of the jail. However, few inmates will participate in voluntary post- release care. To be effective, the post-release aftercare should be mandatory with ongoing monitoring and testing by drug courts.

—Terry L. Bunn, CJM Chief Deputy, Custody Operations

Santa Barbara County (CA) Sheriff’s Department

Barriers to Treatment A number of factors at work in the jail setting have the potential to interfere with effective treatment:

• Lack of funding for services

• Absence of administrative support for devel- oping comprehensive treatment programming

• Tensions between substance abuse and crimi- nal justice systems, which have overlapping but distinctive concerns (e.g., rehabilitation and substance abuse treatment versus safety, control, and punishment)

• Physical space and environment that are not conducive to treatment

• Competing institutional program activities

• Difficulties in developing mechanisms for sharing information between treatment providers and criminal justice staff

• Confidentiality issues and the need to share information

• Lack of case management or continuing care

•Lack of detoxification services

• Detoxification symptoms mistaken for men- tal illness

• Lack of methadone tapered doses for inmates enrolled in methadone treatment programs prior to relapse

• Bringing in family members for family reunification or family therapy without careful security screening

• HIV/AIDS and sexually transmitted diseases among inmates

• Inability to provide HIV/AIDS educational materials

• Institutional restrictions related to video equipment, TVs, VCRs (for video playback of practice job interviews)

• Difficulties implementing community in- reach for supplemental as well as basic treatment services

• Treatment providers’ reluctance to work in jails

The competing goals of the criminal justice and treatment systems can sometimes pose prob- lems, though the systems share many of the same objectives. Figure 8-2 highlights the spe- cific goals of correctional and treatment sys- tems within jail settings and the shared goals of these systems.

Limited resources The limited amount of funding provided for treatment in many jails reflects underlying community attitudes and beliefs. These include the belief that providing services, including treatment, runs counter to a jail’s “purpose” of punishment and may interfere with management. There is also a general lack of knowledge of the impact that treatment can have on crime. Few are aware of the multiple problems that exist in those served by jails, the fluidity of this population between the jail and the community, and the lack of systemat- ic interventions that would stop the expensive jail-streets-jail cycle. Further, the struggle for

176 Chapter 8

Figure 8-2 Goals of the Treatment and Corrections Systems in the Jail Setting

Goals of Treatment System Goals of Corrections System Shared Goals

Behavior change Safety of inmates Reducing crime

Public health Safety of jail personnel Reducing substance abuse

Rehabilitation Punishment Reducing violence

Long-term good of individual and family

Safety of community Changing behaviors

jail treatment resources may mirror the underfunding of treatment in the community. Jail treatment programs may even compete with, or be viewed as competing with, commu- nity resources.

If a community surveys the needs of its jail population, scarce treatment resources can be allocated in a way that is most effective. Jails with adequate resources can develop both specialized and generalized substance abuse treatment services. Jails with fewer resources may choose to divide resources between iden- tification and referral to community pro- grams for inmates who have various co-occur- ring disorders and problems (e.g., people with severe mental illness, the homeless), and providing traditional treatment services to inmates whose primary problem is their sub- stance use disorder.

To more efficiently focus limited resources, the consensus panel suggests that jail-based substance abuse treatment programs have clear goals and objectives tied to reasonable outcomes, given the limitations imposed by the correctional setting. For example, if the goal of jail treatment is to reduce inmates’ negative health consequences related to their substance abuse (e.g., HIV risk), the program would be constructed somewhat differently than if the goal were for maintenance of sus- tained abstinence following release from cus- tody. Jail treatment programs have found it useful to enlist the help of multiple stakehold- er groups that can offer additional resources both in the institution and during transition to the community.

Solutions for Coordinating Jail-Based Treatment Services There are a number of ways substance abuse treatment providers can work to improve ser- vices for people in jails and overcome the barriers described above. These are discussed in the sections that follow.

Prioritizing substance abuse treatment for traditional versus special needs populations Because of scarce resources, many jails find that they must prioritize how to allocate treatment services for inmates with differing levels of treatment needs. One major issue is whether to target populations that require specialized care and that are at greater risk for relapse, criminal recidivism, and high uti- lization of community services (e.g., chroni- cally mentally ill, mentally retarded, or homeless inmates) or to focus resources on inmates with more traditional substance abuse treatment needs. There are advantages and disadvantages related to targeting one group in favor of another. The consensus panel recommends that jails assess their own resources available for treatment and the scope of subpopulations with special treat- ment needs to devise a plan that ideally would address the needs of both groups. Figure 8-3 (p. 178) compares the advantages and disad- vantages of prioritizing substance abuse treat- ment services for traditional and special needs populations.

Promote understanding of institutional security rules and confidentiality requirements An incomplete understanding of the rules related to confidentiality of substance abuse treatment information and to the security guidelines within the institution may lead to conflict between correctional and treatment staff and may reduce the effectiveness and credibility of the treatment program. For example, counselors may unwittingly bring materials into the jail for treatment purposes that could be considered contraband by secu- rity staff or may make promises to inmates regarding scheduled activities, visitation, tele- phone calls, or other privileges that are not

177Treatment Issues Specific to Jails

allowed. A thorough awareness of the rules allows the treatment program staff to antici- pate these difficulties and develop creative solutions. Treatment counselors should be invited, and be willing, to participate in train- ing related to security guidelines and meth- ods. Treatment supervisors could also offer support by advising counselors on techniques for handling safety concerns and conflict with security staff. Finally, treatment and jail supervisory staff can use cross-disciplinary meetings and cross-training activities to joint-

ly address and solve potential areas of con- flict related to housing assignments, schedul- ing, reviewing responses to critical incidents (e.g., dealing with contraband), information sharing, and other aspects of program devel- opment.

Improve coordination of information systems A lack of coordinated information can be a problem for detainees involved in multiple

178 Chapter 8

Figure 8-3 Targeted Treatment for Specific Populations Versus Mainstream

Treatment for Larger Populations

Treatment for Specific Populations Mainstream Treatment

Advantages Disadvantages Advantages Disadvantages

Can increase outreach to detainees and inmates otherwise not identified or provided with treatment

Comprehensive multi- problem screenings and assessments are costly

Rapid identification of detainees through charge category or urine testing

Possibly less effective because intensity of treatment is not matched to inmates’ needs

Can reduce correction- al officer and inmate injuries by providing stabilization and obser- vation of potentially volatile inmates

Committed space and specially trained profes- sional staff are more expensive and could reduce resources to gen- eral substance abuse population

Interventions reach more inmates

Less effective without dis- crete program space and experienced, trained staff

Makes more beds avail- able through reduced cycling of “high-risk” inmates

Requires more aftercare planning staff and coor- dination with community agency visits

Focuses more resources on substance abuse treat- ment

Not as effective with spe- cial needs populations who need more intensive services

Allows for creation of aftercare and commu- nity linkages for special populations

Allows for direct after- care and diversion link- age to reduce negative outcomes and increase positive gains

Requires aftercare plan- ning staff, coordination with community agencies, and coordination with courts, and may increase officer time for court transportation and staffing agency visits

systems. Several nonproprietary computer- ized management information systems have been developed for this purpose. This soft- ware allows efficient, timely, and continuous care through treatment matching and fol- lowup and may also include data on drug test results. One model, based on the University of Maryland’s High Intensity Drug Trafficking Area Automated Treatment Tracking Software (HIDTA-HATTS), enables substance abuse treatment and criminal jus- tice personnel to access the same information in making decisions about the client (Taxman and Sherman 1998). Other proprietary mod- els based on drug courts have expanded their applications to include mental health screens and assessments. Still other jurisdictions have developed mechanisms to share mental health and substance abuse database information between the correctional institution and the community managed care provider (e.g., National GAINS Center 1999c). Each juris- diction involved in developing these types of management information systems has worked out informed consent and differential confi- dentiality issues for information sharing. The models cited have also developed their work in the context of multisystem collaboration and at times through formal consensus-build- ing processes between the key stakeholders relevant to ensure continuity of treatment (Broner et al. 2001b).

Educate staff regarding pharmacotherapies Some jail administrators resist using pharmacotherapy because they are philosophically opposed to administering medication (e.g., methadone, psychiatric medications) to people with sub- stance abuse problems, but most jails administer a range of psy- chiatric medications for inmates with mental disorders. Most of these medications are not addic- tive and do not present a risk for distribution as contraband

within the institution. However, relatively few jails provide medication-assisted treatment for opioids and other drugs. Figure 8-4 (p. 180) describes some of the advantages and disadvantages of medication use, for inmates enrolled in jail substance abuse treatment programs.

There are legitimate concerns regarding the use of some medications in jails, particularly when there are not adequate healthcare staff available to monitor and supervise medication use. Pharmacological treatments used in jails should be monitored by a qualified physician or nurse practitioner. Project KEEP is an example of a program that integrates pharma- cological treatments with a jail environment (see p. 181).

Provide for staff development Many front-line jails require that staff have only a GED or high school diploma and no criminal record. While correctional staff receive extensive security training, training is not always provided in working with specific populations and substance abuse treatment. Cross-training is an effective approach to have correctional and treatment staff learn from each other about key issues related to institutional security and rehabilitation. Correctional officers can benefit from learn- ing about the length, course, and components of substance abuse treatment; effective com-

179Treatment Issues Specific to Jails

Advice to the Counselor: Cross-Training

• Treatment and corrections staff should learn from each other.

• Counselors in correctional settings can benefit from training in security guidelines, and learning about inmate behavior and attitudes.

• Correctional staff can benefit from training in working with specific populations, components of substance abuse treatment, and their role in shaping a therapeutic environment.

munication strategies with treatment staff regarding inmate behavior and attitudes; involvement in treatment team, group meet- ings, and other unit activities; and their role in shaping a therapeutic environment. Treatment staff can benefit from training related to security guidelines, effective com- munication with corrections staff regarding inmate behavior, contraband and other secu- rity infractions, and their role in maintaining the security of the housing unit and the jail. Both corrections and treatment staff can be productively involved in identifying critical incidents that may occur within the jail treat- ment unit, the type of information that needs to be shared between treatment and correc- tions staff, and methods of resolving these sit- uations.

Instituting treatment programs within jails creates a unique opportunity for treatment staff to collaborate with jail staff in develop- ing in-service training programs and to encourage certification and degree training at local universities. For instance, New York City offers incentives and tuition reimburse- ment for city employees for both undergradu-

ate and graduate training, along with a foren- sic certificate, through the New York University school of social work. Flexible job scheduling could help many employees improve their education, and providing course work for credit at the job site would allow jail personnel to work toward under- graduate or graduate degrees. Another option is to set aside time for career development on the job—with a few hours per week to take a class that will not only help their job perfor- mance, but will also aid their career progress.

Developing community and correctional partnerships Creating partnerships between the jail and the community can allow for the development or enhancement of both in-jail treatment pro- grams and coordination of offenders’ transi- tion into community diversion and aftercare/ reentry programs. Such a model of coopera- tion and collaboration exists in many jails in the areas of education and health care or in some jails for diversion and aftercare of those with substance use disorders or other mental

180 Chapter 8

Figure 8-4 Varied Opinions Regarding Medication Use for Inmates

in Jail Treatment Programs Advantages Disadvantages

Provides continuous treatment from community to jail, and jail to community

Belief that “drugs” should not be tolerated in jails

Reduces cravings Medications used to combat withdrawal may be used as contraband

Provides a humane response to treating symptoms of withdrawal and addiction

May lead to inmates’ selling or trading the medication within the population

Medications are constantly being developed and improved that can benefit inmates with substance abuse and mental health problems

Side effects are not always known

Benefits of treating medical problems (substance use disorders) medically

Benefits to learning to deal with problems without drugs

Resolves/improves symptoms of mental illness and allows the dually diagnosed individual to focus on substance abuse issues

Some medications (e.g., benzodiazepines) can be addictive

disorders (Broner et al. 2002; Steadman et al. 1995). Such partnerships allow for the exten- sion rather than duplication of an array of community resources to address many of this population’s substance abuse, mental health, medical, vocational, educational, and social service needs.

On the other hand, coordinating the visits of large numbers of community volunteers can create both a security and staffing burden for the jail. Concerns include staffing patterns, security, contraband monitoring, coordinat- ing schedules, staff time, escorting inmates to their group room and back, and escorting vis- itors. Therefore, arranging for services from the outside produces an additional workload for jail administrators that may in itself be a barrier. To overcome these problems, shared funding and community organizations’ bud- geting for jail officers’ time could be employed. To find a compatible blend of needs and concerns on both sides, there must be a planning structure for community volun- teers and jail administrators to facilitate com- munication and resolve problems.

Creating linkages between jail treatment and diversion and reentry court programs Although typically operated by the criminal courts, drug treatment courts (DTCs) have formed productive partnerships with local jails in many jurisdictions (Tauber and Huddleston 1999). The first phase of treat- ment in some drug court programs is complet- ed in jail, with intensive services provided that focus on a comprehensive psychosocial assessment, substance abuse education, and engagement in and orientation to treatment. In other drug court programs, an initial in- jail treatment component is optional, depend- ing on the severity of drug treatment needs and the importance of a secure treatment set- ting. Jail treatment is also used with inmates who are awaiting placement in drug court treatment programs in the community. Another major function of jail treatment pro- grams is to provide more intensive services on a short-term basis for drug court participants who relapse or commit other major infrac-

181Treatment Issues Specific to Jails

Project KEEP

A significant increase in the number of drug-related arrests in the New York Metropolitan area in 1987 led to overcrowding and unrest at the Correctional Facility on Riker’s Island. In response, researchers developed a program that serves as both a methadone program and an AIDS prevention initiative. Called KEEP (Key Extended Entry Program), the program enables opioid-dependent offenders who are charged with misdemeanors to be maintained on a stable dose of methadone during their stay at Riker’s, and then receive a referral at release to a participating community methadone program. KEEP, intend- ed to be a route into long-term community drug treatment, aims to break the cycle of illicit drug use and criminal recidivism. It was one of the first methadone treatment programs of its kind in the United States for incarcerated persons addicted to heroin (Tomasino et al. 2001). This program allows for a humane detoxification for offenders who desire it upon entry to jail, and it allows new patients to enroll in maintenance and to receive treatment in the community. Finally, and most importantly, it provides a continuity of care upon release from jail to people enrolled in methadone therapy prior to arrest.

Seventy-four to 80 percent of methadone treatment patients discharged to the community, mostly to out- patient KEEP programs, report to their designated program. Recidivism rates show that 79 percent of KEEP patients were re-incarcerated only once or twice during a recent 11-year period. KEEP data indi- cate the importance of administering sufficient blocking doses of methadone to patients in outpatient treatment centers in order to eliminate heroin craving and to maintain the patients in treatment. About 6 percent of KEEP patients are at a higher risk for recidivism (e.g., those with co-occurring disorders) and require specialized treatment (Tomasino et al. 2001).

tions. In these cases, jail programs can serve as a therapeutic sanction to remove an indi- vidual from salient relapse cues (such as drug-using peers), to provide detoxification as needed, and to reengage individuals in their recovery programs. Many drug courts use progressive sanctions that provide an escalat- ing number of days in jail (e.g., 2, 4, 7) for designated program infractions. In some cases, drug courts have provided longer jail

sentences, although the therapeutic effects of these sanctions are unclear.

Several drug courts have established a coordinated reentry approach with in- jail treatment pro- grams (Huddleston 1998; Tauber and Huddleston 1999). Each of these part- nerships is charac- terized by signifi- cant flexibility in addressing the indi- vidual needs of

drug court participants. Many of these drug courts also continue to monitor participants who are placed both in custodial and noncus- todial settings. For instance, two drug court and jail treatment partnerships (Los Angeles County and San Bernardino County, California, and Uinta County, Wyoming), place offenders in the jail treatment program as the first phase of drug court. In the San Bernardino drug court, participants are given job assignments within the jail that allow for attendance in treatment groups and classes. In Los Angeles County, a separate housing unit is reserved for drug court treatment and receives referrals from several drug courts in the county. One Los Angeles drug court, designed for probation violators (one of 11 drug courts in the county), requires 3 months’ in-jail treatment prior to completing subsequent phases of the program. In Uinta

County, Wyoming, drug court participants who have been unsuccessful in court-ordered treatment are placed in a 6-week jail treat- ment program as the first phase of drug court involvement. While they are in the jail treat- ment program, participants in Uinta County are required to appear in drug court once weekly for status hearings.

In Broward County, Florida, the DTC refers participants to a 90-day jail treatment pro- gram if they have not successfully completed other less intensive approaches (e.g., outpa- tient treatment) (Tauber and Huddleston 1999). Individuals sentenced to jail prior to involvement in the Broward County drug court are also referred to the jail treatment program to engage them in treatment quickly. The drug court then monitors their progress in the jail treatment program and provides a reentry mechanism upon their transfer to the drug court program.

In New Castle County, Delaware, the DTC has combined both short-term (6 months) and long-term (11–18 months) custodial substance abuse treatment with continued care upon rearrest for probation violators who have committed new felony-level offenses. The court monitors the individual’s progress through the prison- or jail-based treatment and develops a reentry treatment plan based on input from team members. This has had a positive effect on reducing recidivism (Statistical Analysis Center 1998).

Several other drug court and jail treatment partnerships offer unique elements. In Los Angeles County drug courts, participants who are transferring from the jail treatment unit to community settings can use transition housing. In San Bernardino County, a com- prehensive assessment is provided after 10 weeks of treatment in the jail program and is provided to the drug court judge before sta- tus hearings. This assessment serves as the basis for the court’s decision to order contin- ued in-jail treatment, placement in a commu- nity residential treatment program, or place- ment in a community outpatient program. In

182 Chapter 8

Jail programs can

serve as a

therapeutic sanc-

tion to remove an

individual from

salient relapse

cues.

New Haven, Connecticut, the drug court judge orders jail sentences as a sanction and requests on an individual basis that drug court participants receive priority access to drug treatment and self-help groups during the ensuing period of jail incarceration (Huddleston 1998). For more information on drug courts and diversion programs, see chapter 7.

Examples of Jail Treatment Programs Several innovative components and unique fea- tures of metropolitan jail substance abuse treatment programs are described in this section.

Multnomah County Sheriff’s Office In-Jail Intervention Program (Portland, Oregon) • Offers a specialized co-occurring mental dis-

orders emphasis and features domestic vio- lence services and a relapse prevention track.

• Provides acupuncture treatment to assist inmates in dealing with cravings and with- drawal symptoms during the initial stage of treatment.

• Offers an intensive short-term treatment program (22 days, 50 hours per week, 1:7 staffing ratio) with significant emphasis on aftercare linkage.

• Provides transition and linkage services, which includes driving inmates to communi- ty treatment providers (often residential services), as needed, and picking up medi- cations and refilling prescriptions prior to the aftercare placement.

• Coordinates with community treatment providers to share information about after- care treatment plans and other records.

• Plans aftercare programs that include case management and client needs assessment.

• Offers a treatment curriculum shaped in part by results of satisfaction surveys administered to inmates.

King County Jail System, North Rehabilitation Facility, Stages of Change Program (Seattle, Washington) • Provides an integrated system of

“wraparound” treatment services.

• Partially funded through work contracts.

• County’s Department of Public Health man- ages the jail.

• Offers screening and triage for inmates placed in the jail for more than 1 week.

• Provides individual sessions with counselors.

• Offers acupuncture services.

• Assigns all inmates to jobs that have the potential of developing employment skills.

Philadelphia Prison System OPTIONS Program (Philadelphia, Pennsylvania) • Provides gender-specific programming for

women.

• Provides relapse prevention services, com- bined with modules on the “psychology of achievement” and entrepreneurship training, using motivational and action-oriented strate- gies of Fortune 500 companies.

• Integrates family therapy sessions in which families come into the jail.

• Program staff make home visits.

• Program staff use videotaped material from jail and home-base settings for inmates and their families.

• Provides aftercare followup services.

183Treatment Issues Specific to Jails

Wayne County Jail Target Cities Jail-Based Substance Abuse Treatment Program (Detroit, Michigan) • Diverts nonviolent prison inmates to complete

short-term jail treatment services, followed by involvement in community treatment.

• Reduces the need for prison space through cost-effective diversion approach.

• Addresses parenting skills and parental financial responsibility for family members.

• Uses feedback from an external evaluator to intensify services during the first 3–4 weeks of program involvement, the period in which many participants historically drop out.

• Offers an “Alumni Success” group for pro- gram participants.

Walden House and the San Francisco Sheriff’s Office SISTER Project (San Francisco, California) • Prepares incarcerated women for life after

their release to prevent relapse.

• Encourages women to make productive use of their time in this 30- to 45-day program.

• Offers a 6-week academic course that pro- vides women with information about college admission and financial aid.

• Provides five-stage testing for GED (high school equivalency) weekly, and holds cap and gown ceremony for graduates.

• Introduces women to a variety of potential job options and helps them to prepare their resumes in a computer class.

• Counsels women on how to keep a job after securing it.

• Prepares women for treatment and places them in community-based programs after their release (Chadwick 2001).

Research Related to Jail Treatment A survey of metropolitan jail treatment pro- grams indicates that many jails have several treatment phases and endorse more than one therapeutic orientation (Peters and May 1992). More than half of the jail programs surveyed included 12-Step groups, cogni- tive–behavioral groups, and relapse preven- tion programs. Many jail treatment programs have developed specialized tracks for such groups as juveniles charged as adults, those with co-occurring disorders, groups for peo- ple arrested for driving under the influence, and blended groups for domestic violence and substance abuse (Peters and Mathews 2002).

Outcomes of Jail Treatment Jail treatment programs often are dependent on local resources or knowledge, rather than on consistent best practice models for this set- ting. While outcome studies are few and limit- ed in scope, the therapeutic community model shows promise even for short-term stays. In particular, the Amity/Pima County Substance Abuse Treatment Jail Project, funded by the U.S. Bureau of Justice Assistance in the late 1980s, demonstrated the efficacy of drug treatment in a correctional setting (Pima County Sheriff’s Department 1988). Moreover, a number of studies demonstrate reduced rearrest and reconviction rates, longer time to rearrest, and fewer arrests during follow-up for those participating in in- jail drug treatment (Peters and Matthews 2002).

Effects of Treatment Duration Studies investigating the effects of duration of jail substance abuse treatment indicate that recidivism rates are related to the length of treatment, up to an optimal duration of 91–150 days (Swartz et al. 1996). Successful treatment outcomes have been reported for jail programs of 1.5–5 months duration. Involvement in aftercare treatment services

184 Chapter 8

following release from jail has also been found to reduce criminal recidivism (San Francisco County Sheriff’s Office Department 1996; Swartz et al. 1996). Offenders released from jail are more likely to participate in aftercare treatment if they have previously been involved in a jail treatment program (Taxman and Spinner 1997).

Predictors of Treatment Outcomes A number of studies have examined predic- tors of jail treatment outcomes—what ele- ments help people finish treatment (“com- pleters”) and what elements militate against completion (“noncompleters”). The most important predictor in one study examining rearrest during a 1-year follow-up period was the number of lifetime arrests, although other psychological indicators and living arrange- ments were also found to be predictors (Peters et al. 1993). A similar study (Peters et al. 1999) found that cocaine users were less likely to complete a treatment program than alcohol or marijuana users. Other factors predicting noncompletion were lack of a high school diploma, living outside a parent’s home, lack of full-time employment, and hav- ing been arrested for charges other than drug possession. It is likely that similar factors may influence retention in jail treatment pro- grams, although more research is needed in this area.

Importance of Aftercare Unfortunately, a majority of released detainees are not linked to aftercare services or treatment and the majority of jails do not use diversion resources such as drug courts. Treatment mandated by drug courts is associ- ated with decreased recidivism, increased treatment retention, and better aftercare linkages (Leukefeld and Tims 1988). Tunis and colleagues (1997) found that drug treat- ment programs in jails provide a “behavioral management tool” that results in fewer behav- ioral problems, especially physical violence.

However, effects of the program on recidivism rates were modest in the year after release. Inmates participated in the treatment on a voluntary basis in the programs they studied, which consisted of counseling and self-help groups and aftercare opportunities in the community were extremely limited. Additional training for correctional staff could have increased their support for aftercare.

Recommendations for Treatment Providers The consensus panel believes that to maximize the benefits of substance abuse services, treat- ment staff working with clients in jails should consider the following recommendations:

• Recognize that many people in the communi- ty frequently move back and forth from com- munity to jail and that triage and referral to services can be critical.

• For individuals in community treatment agencies, make staff available to provide ser- vices in jails and share expertise through training and consultation with jail treatment staff.

• Provide ongoing consultation to jail adminis- trators and other jail staff about substance abuse issues, and work to establish a continu- um of services in the jail and community for people with substance abuse problems.

• Develop treatment approaches that are tar- geted to recognized special populations, such as those described in this chapter.

• Assist in conducting periodic quality assess- ment reviews.

• Employ evidence-based practices such as motivational enhancement techniques, cogni- tive–behavioral interventions, relapse pre- vention, contingency management, and ther- apeutic communities.

185Treatment Issues Specific to Jails

187

9 Treatment Issues Specific to Prisons

Overview The unique characteristics of prisons have important implications for treating clients in this setting. Though by no means exhaustive, this chapter highlights the most salient issues affecting the delivery of effective treatment to a variety of populations within the prison sys- tem. It describes the prison population as of 2003, reviews the treat- ment services available and key issues affecting treatment in this set- ting, and considers the question, “what treatment services can reason- ably be provided in the prison setting?” The prison therapeutic com- munity (TC) model is explored in depth and examples of in-prison TCs are described. The chapter also looks at the treatment options available for certain specific populations and at systems issues that affect all clients in prison settings. The chapter concludes with some general recommendations for substance abuse treatment in prisons.

Description of the Population Prisons differ from jails in that inmates generally are serving longer periods of time (1 year or longer) and the offenders have often com- mitted serious or repeated crimes. Prisons and jails both vary in size, but prisons are unique in that they are separated by function and inmate classification. Types of prisons include

• Intake facilities (processing centers for inmates receiving orientation, medical examinations, and psychological assessment)

• Community facilities (halfway houses, work farms, prerelease centers, transitional living facilities, low-security programs for nonviolent inmates)

• Minimum security prisons (dormitory style housing for inmates classi- fied as the lowest risk levels serving relatively short sentences for non- violent crimes)

• Medium security prisons (higher security risks such as those with a his- tory of violence)

In This Chapter… Description of the

Population

Treatment Services in Prisons

Key Issues Affecting Treatment in Prison

Settings

What Treatment Services Can Reasonably Be

Provided in the Prison Setting?

In-Prison Therapeutic Communities

Specific Populations in Prisons

Systems Issues

Recommendations and Further Research

• Maximum security prisons (most restrictive prisons for violent inmates and those posing the highest security risks)

• Multi-use prisons (inmates of different securi- ty classifications generally used in States with smaller prison populations)

• Specialty prisons (for inmates with special needs, such as people with mental illness, physical disabilities, or HIV/AIDS) (National Center on Addiction and Substance Abuse [CASA] 1998).

At the end of 2003, State and Federal prisons in the United States housed a total of 1,470,045 inmates. This meant that there were approximately 482 sentenced inmates for every 100,000 United States residents. About 1 in every 109 men and 1 out of every 1,613 women were incarcerated by State or Federal authorities. The Nation’s prison pop- ulation grew 2.1 percent in 2003 (Harrison and Beck 2004).

The percentage of prison inmates incarcerat- ed for parole violations has decreased in recent years. Between 1990 and 1998, the number of people in prison for parole viola- tions increased by 54 percent, but since 1998 the number of parole violators has increased less than 1 percent (Harrison and Karberg 2004).

Gender Since 1995, the rate of incarceration of women in prisons has increased at a higher rate (5 percent on average) than that of men (3.3 percent). In 2003, the number of women in State or Federal prisons increased by 3.6 percent, while the number of men in those institutions increased by 2 percent. Women accounted for 6.9 percent of all inmates in State and Federal prisons as of yearend 2003, an increase from 5.7 percent of all inmates in 1990 (Harrison and Beck 2004).

Race and Ethnicity Although the total number of sentenced inmates increased greatly over the past decade, only a slight variance existed in the racial and ethnic composition of the inmate population. At yearend 2003, African- American males (586,300) outnumbered Caucasian males (454,300) and Hispanic/Latino males (251,900) among inmates with sentences of more than 1 year. African-American inmates represented an estimated 44 percent of all inmates with sen- tences of more than 1 year, while Caucasian inmates accounted for 35 percent and Hispanic/Latino inmates, 19 percent. More than 9 percent of all African-American men between the ages of 25 and 29 were in prison in 2003 (Harrison and Beck 2004).

Substance Abuse The lifetime incidence of substance abuse or dependence disorders in the prison popula- tion is roughly 75 percent (Peters et al. 1998). In 2001, 20 percent of State prison inmates were incarcerated for drug-related offenses (Harrison and Beck 2003).

In a 1997 Bureau of Justice Statistics survey, approximately half of all State and Federal inmates reported that they had used drugs in the month before their offense, and over three-quarters indicated that they had used drugs during their lifetime (Mumola 1999). Almost one in three prisoners said they had committed their current offense while under the influence of drugs, and about one in six had committed their offense to get money for drugs. In addition, a quarter of State and a sixth of Federal prisoners had experienced problems consistent with a history of alcohol abuse or dependence. Drug offenders accounted for more than half the total increase in parole violators returned to State prisons (Beck 2000b).

Offenders who use drugs are more likely to commit violent crimes. In a report by CASA (1998), almost half (43 percent) of those iden-

188 Chapter 9

tified as “regular drug users” in State correc- tional systems were incarcerated for a violent offense, including murder, manslaughter, rape, robbery, kidnapping, and aggravated assault.

Mental Illness At midyear 1998, 16 percent of State prison- ers and 7 percent of Federal inmates reported having a mental condition (Ditton 1999). As of 2000, 13 percent of State prison inmates (approximately 79 percent of those with men- tal disorders) were receiving some type of reg- ular counseling or therapy from a trained professional. Approximately 10 percent of all inmates in State prisons were receiving psy- chotropic medication (Beck and Maruschak 2001).

According to 1998 data, State prison inmates who reported having a mental condition were more likely than other inmates to be incarcer- ated for a violent offense (53 percent com- pared to 46 percent). They were also more likely than other inmates to be under the influence of alcohol or illicit substances at the time of the current offense (59 percent versus 51 percent), and more than twice as likely as other inmates to have been homeless within the previous 12 months (20 percent compared to 9 percent) (Ditton 1999). Approximately 78 percent of females and 33 percent of males in State prisons who have a mental illness reported they had been physically or sexually abused at some point in their lives (Ditton 1999).

Many offenders in State or Federal prisons who had a mental illness reported negative life experiences related to drinking, including losing a job, getting arrested, and getting into a fight. Inmates with a mental illness were also more likely than others to be under the influence of alcohol or drugs while committing their offense; 60 percent of State prisoners who had a mental illness compared to 51 per- cent of other inmates were under the influ- ence when they committed their offense (Ditton 1999).

Communicable Diseases Many offenders in State and Federal prisons have poor general health. Their access to and use of healthcare services may have been lim- ited, and behaviors such as intravenous drug injection and unsafe sex may have exposed them to communicable diseases. Prisoners have disproportionate rates of HIV, hepatitis C (HVC), sexually transmitted diseases, and tuberculosis (TB) (Hammett 1998; HIV and Hepatitis Education Prison Project 2002; Maruschak 2004).

HIV and AIDS The number of all State and Federal prison inmates with HIV infection is esti- mated to be nearly six times higher than that of the general population (Hammett 1998). In recent years, the rate of infection has decreased somewhat for the general prison population. The number of pris- oners known to be infected with HIV was down from 2.2 percent in 1998 to 1.9 percent at yearend 2002. The number of State and Federal prison inmates known to have AIDS also decreased from 5,754 reported cases in 2001 to 5,643 in 2002 (Maruschak 2004). As in the general popula- tion, HIV infection rates were higher for racial minorities. In 1997, of all State prison inmates, 2.8 percent of African-American inmates and 2.5 percent of Hispanic/Latino inmates, compared to 1.4 percent of Caucasian inmates, reported to survey inter- viewers that they were HIV positive (Maruschak 1999b).

189Treatment Issues Specific to Prisons

The lifetime

incidence of

substance abuse

or dependence

disorders in the

prison population

is roughly

75 percent.

Hepatitis C Many inmates also have HVC. According to the HIV and Hepatitis Education Prison Project (2002), the rate of HCV infection is 10 times higher than that of HIV—an estimat- ed 17 percent of inmates, nearly 10 times higher than the estimates for the general pop- ulation. Like HIV infection, rates are higher among incarcerated women. Nationally, HVC is about a third higher in incarcerated women than incarcerated men.

Tuberculosis Rates of TB are also higher among State and Federal inmates than in the general popula- tion. Wilcock and colleagues (1996) note that many men who eventually enter prison are at risk even before they are incarcerated. Poverty, poor living conditions, substance abuse, and HIV/AIDS put them at increased risk. Once in prison, these offenders are at risk for contracting TB, as prisons present optimal conditions for the spread of TB. According to 2003 data, nationwide 3.2 per- cent of residents of correctional facilities had TB (Centers for Disease Control and Prevention 2004b). A 1994 study of 25 State and Federal inmates by Wilcock and col- leagues (1996) reported that 5,609 inmates who did not test positive for TB when enter- ing prisons did so 2 years later.

Treatment Services in Prisons The need for prison-based substance abuse treatment is profound. Lo and Stephens (2000) examined treatment needs of Ohio offenders entering the State prison system. More than half were dependent on at least one substance, and 10 percent were depen- dent on at least two. Treatment for cocaine and marijuana dependence was most urgently needed. Young minority males were most like- ly to be dependent on marijuana; females were more likely to be dependent on cocaine and opioids than males. Nearly 60 percent of

respondents said that treatment would be of use to them.

Despite this need, in 1997 only 1 in 8 State prisoners and 1 in 10 Federal prisoners reported that they have participated in drug treatment programs since entering prison (Mumola 1999). In 1996, a CASA survey of prison facilities indicated that three quarters of State inmates needed substance abuse treatment, though less than a quarter of State inmates received it (CASA 1998). As Figure 9- 1 indicates, the most common reasons listed for the limited availability of treatment were budgetary constraints (71 percent) and space limitations (51 percent).

Various organizations and agencies have developed, or are in the process of develop- ing, guidelines for substance abuse treatment in correctional facilities, including the American Correctional Association (ACA) in conjunction with Therapeutic Communities of America, the National Institute of Corrections (NIC), and the Center for Substance Abuse Treatment (CSAT). Figure 9-2 (see p. 192) summarizes some of these guidelines.

Although the extent to which State prison sys- tems have adopted these professional guide- lines is unclear, they provide a standard against which treatment programs can be measured (Peters and Steinberg 2000).

Key Issues Affecting Treatment in Prison Settings Incarcerated prisoners are marked by consid- erable diversity, yet they share a common experience of incarceration. Prisons can be violent, harsh, psychologically damaging envi- ronments; incarcerated people live in an envi- ronment that is both depersonalizing and dehumanizing. Moreover, the social stigma associated with incarceration, combined with the depersonalizing effects of imprisonment, may result in a sense of hopelessness and powerlessness, as well as deeply internalized

190 Chapter 9

shame and guilt. Thus, in addition to treating substance abuse and other mental disorders, the consensus panel recommends that in- prison treatment also address the trauma of the incarceration itself as well as a prison cul- ture that conflicts with treatment goals.

Trauma and Hopelessness Inmates’ responses to prison environments vary, but virtually all will experience some degree of trauma and hopelessness. Derosia (1998) conducted a review of the literature and determined that the inmates who were most likely to have difficulty coping in prison

• Have unstable family, living, work, and/or education histories

• Are single, young, and male

• Exhibit histories of chronic substance abuse or psychological problems

When accompanied by violence and exploita- tion from other inmates or custodial staff, the sense of trauma and hopelessness can be mag- nified. Sexual assaults are particularly devas-

tating, with a series of accompanying medical, psychological, and social costs (Dumond 2000).

Even for inmates who do not suffer abuse or exploitation while in prison, the trauma of incarceration alone may worsen existing post- traumatic stress disorder (PTSD) or create PTSD-like symptoms. Markers of PTSD include

• Irritability

• Hypervigilance

• Sleep difficulties

• Restricted range of affect

• Feelings of detachment

• Flashbacks and/or nightmares of traumatic incidents (American Psychiatric Association 2000)

Counselors should be able to recognize these symptoms and encourage clients to talk about their feelings related to the incarceration. Counselors should be especially aware of signs of suicidal ideation. For more informa- tion on PTSD see the forthcoming TIP

191Treatment Issues Specific to Prisons

Figure 9-1 Reasons for Limitations to Providing Treatment to Prison Inmates

Reason Percentage

Budgetary constraints 71

Space limitations 51

Limited number of counselors 39

Lack of volunteer participants 18

Frequent movement of inmates 12

General correction problems 8

Problems with aftercare provision 4

Legislative barriers 2

Source: CASA 1998.

Substance Abuse and Trauma (CSAT in development f), and TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT 2005c).

Inmate Identity and Culture It is difficult to describe one type of “crimi- nal” identity that is shared by all offenders. A more common problem is, perhaps, the lack of identity and accompanying hopelessness that many offenders face. Some offenders feel relatively little anxiety regarding their incar-

192 Chapter 9

Figure 9-2 Guidelines for Substance Abuse Treatment in Correctional Facilities

ACA NIC CSAT

Screening and assessment

• Diagnosis of chemical dependency by a physician and determination of whether that individual requires pharmacologically supported care

• Screening and assess- ment

• Standardized screening and assessment

Treatment plans • Individualized treatment plans

• Development of com- prehensive treatment services

• Continuity of services across the corrections system

• Individualized treatment plans

Other • Referrals to community resources upon release (ACA 1990)

• Staff recruitment

• Staff training

• Sanctions

• Program accountabil- ity and evaluation (NIC 1991)

• Matching to different levels or types of treatment ser- vices

• Case management services

• Use of cognitive–behavioral, social learning, and self- help approaches

• Inclusion of relapse preven- tion training

• Use of self-help groups

• Use of therapeutic commu- nities

• Provision for isolated treat- ment units

• In-prison drug testing

• Continuity of services

• Program evaluation

• Cross-training of staff

Sources: ACA 1990; CSAT 1993; NIC 1991.

ceration, and many believe that being in prison and participating in prison culture are the norm. Others feel they are the victims of society, and still others take pride in belong- ing to an alternative culture (e.g., the drug culture, a gang) and being outside the majori- ty culture.

Unlike jail detainees, who are likely to be incarcerated for short terms, prisoners often learn to identify as inmates as a matter of survival. In part, this is a result of institu- tional pressures on them, and partly it is the result of interactions with other inmates who have accepted the role or persona of a prison- er. In prisons, as opposed to jails, there are many more people who are accustomed to the setting and who take the attitude that it is “no big deal.” The assumption of an identity as an inmate is an issue of survival for most offend- ers. The hardened demeanor and “macho” attitude adopted as part of the inmate culture can discourage offenders from participating in treatment. Treatment is often perceived as a sign of “weakness” within the inmate cul- ture, and inmates who enroll in treatment are often characterized by other prisoners as too weak to “handle their drugs” in the communi- ty.

Gender-Specific Issues Gender in particular is a defining category for treatment and recovery in prison settings. Populations are segregated by gender so that in addition to the difference in psychosocial issues facing male and female inmates, the character and experience of men’s and women’s prisons are widely divergent. Programs must be attuned to the differences inherent in treating men and women within a prison setting. For more information on gen- der-specific issues, see chapter 6 of this TIP and the forthcoming TIPs Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in development g) and Substance Abuse Treatment and Men’s Issues (CSAT in development e).

Men in prisons The consensus panel suggests that, where pos- sible, programs provide specific groups and educational curricula that emphasize the gen- der-specific aspects of treatment. For exam- ple, issues related to relationships and to fatherhood should be explored. Fathers may be encouraged to participate in parenting education, with an emphasis on responsibili- ties and the impact of neglect, anger, and abuse on children.

Employing both male and female counselors is helpful in an all-male program, as male inmates may be less guarded and confronta- tional with female staff. Treatment staff also should focus on gender dynamics that affect many male participants’ willingness to assess honestly their own conduct, typically includ- ing behaviors such as avoiding responsibility, excessively blaming others, and repressing feelings.

For many incarcerated men, learning to express anger in healthy and constructive ways is vital. Many male offenders have been perpetrators of domestic and/or sexual vio- lence and/or have gotten into trouble because of fighting or assaults. Violence prevention groups may help participants explore thoughts, feelings, and behaviors that are often the underpinnings of violent behavior and sexual aggression—issues such as a lack of empathy, narcissism, anger management problems, an overblown sense of entitlement, and the lack of effective thinking skills and sense of self-efficacy.

Research shows that sexual offenders may be at greater risk for violent assaults by other offenders (Brady 1993). By taking a “scatter- shot” approach that treats all participants as if they have a history of violence or sexual offenses, rather than singling out specific individuals, treatment providers can address latent and manifest coercive behavior focus- ing attention on specific individuals.

193Treatment Issues Specific to Prisons

Women in prisons Incarcerated women typically have a constel- lation of high-risk environmental, medical, and mental health issues as well as behaviors associated with continued or renewed sub- stance abuse (CSAT 1999b). In the prison environment, these factors can operate as influences to relapse. They include antisocial behavior, emotional problems, the trauma of imprisonment, and the separation of the inmate from her family and loved ones, espe- cially children. Problematic behaviors and the attitudes that influence them have been developed over many years and often have their roots in childhood trauma. Often, the trauma and related negative influences of imprisonment counteract the value of services provided by the in-prison treatment provider. Imprisonment also disrupts family life and social relationships, thereby interfering with female inmates’ roles as wife/partner, mother, sister, aunt, and daughter. Women inmates’ identities in most cases are tied to one or more of these roles. For some women, inter- ference with these roles produces stress because of the loss of affection and security normally provided by their families, which can also trigger substance abuse.

What Treatment Services Can Reasonably Be Provided in the Prison Setting? Because the prison population tends to be incarcerated for longer periods than jail inmates, treatment possibilities in a prison setting are more extensive, depending on funding and other factors. Counselors and prison administrators may establish programs that are long term and comprehensive. Substance abuse issues may be addressed along with behavioral, emotional, and psy- chological problems. Ideally, prisoners have

the opportunity to abstain from substances and learn new behaviors before release.

Treatment Intensity Treatment in a prison setting can vary greatly in the setting and intensity of the program. On the most intense end of the spectrum, the TC is a treatment model that attempts to cre- ate a 24-hour, 7-day-a-week treatment envi- ronment that integrates community, work, counseling, and education activities. Ideally, the program activities take place apart from the general prison population. Complete iso- lation from the general population is some- what unusual, however.

Less intensive treatment programs may sim- ply deliver counseling, education, and other treatment services in a manner similar to out- patient programs. Inmates live in the general population and have assignments or appoint- ments for services. Examples include weekly or twice-weekly individual therapy, weekly group therapy, or a combination of the two in association with self-help activities.

Regardless of whether treatment occurs in a TC or as isolated outpatient sessions, intensi- ty generally decreases over time as the indi- vidual meets treatment goals and moves through the stages of recovery.

Treatment Components In-prison treatment incorporates several dif- ferent models, approaches, and philosophies for the treatment of substance use disorders, as described in the following section.

Counseling In its prison study, CASA found that 65 per- cent of prisons provide substance abuse coun- seling. Of those, 98 percent offered group counseling and 84 percent offered individual counseling. Nearly one-quarter (24 percent) of State inmates and 16 percent of Federal inmates participated in group counseling while incarcerated (CASA 1998).

194 Chapter 9

Group counseling As the most common treatment method, group counseling seeks to address the under- lying psychological and behavioral problems that contribute to substance abuse by pro- moting self-awareness and behavioral change through interactions with peers (CASA 1998). Although the intensity and duration of group therapy can vary, trained professionals typi- cally lead groups of 8 to 10 inmates several times a week with the expectation that partici- pants will commit to and engage in meaningful change in an emotionally safe environment. Group sessions typically range from 1 to 2 hours in length.

Cognitive–behavioral groups Substance abuse treatment programs in cor- rectional settings should be organized accord- ing to empirically supported approaches (i.e., those based on social learning, cognitive– behavioral models, skills training, and family systems) (Cullen and Gendreau 1989). Programs based on nondirective approaches or medical models or those focusing on pun- ishment or deterrence have not been shown to be effective (Peters and Steinberg 2000). Cognitive programs include such strategies as “problem solving, negotiation, skills training, interpersonal skills training, rational–emotive therapy (REBT), role-playing and modeling, or cognitively mediated behavior modifica- tion” (Izzo and Ross 1990, p. 139).

Cognitive/behavioral/social learning models emphasize interventions that assist the offender in changing criminal beliefs and val- ues. Such interventions concentrate on the effects of thoughts and emotions on behav- iors, and include strategies (e.g., behavioral contracting) that promote prosocial behavior and accountability through a system of incen- tives and sanctions. Examples of cognitive– behavioral group interventions include the National Institute of Corrections’ Thinking for a Change curricula (online at www.nicic.org/pubs/2001/016672.htm), the Criminal Conduct and Substance Abuse

Treatment (Wanberg and Milkman 1998), and others described in chapter 5 of this TIP.

In REBT, the client’s thinking patterns are also the focus of attention. Individuals who abuse substances tend to think automatically, in rigid terms, and with overgeneralizations. Rationalizations are also commonly used by offenders to justify maladaptive behaviors, including substance abuse and a range of other criminal behaviors. Clients are taught to be aware of their thinking patterns and to challenge their assumptions. Once these errors in a client’s thinking are pointed out, they can be changed. Correcting the client’s thoughts can lead to exploration of alterna- tive behaviors and attitudes that do not involve substances.

Specialty groups Specialized treatment groups are often orga- nized around a shared life experience (e.g., children of alcoholics, incest survivors, peo- ple with AIDS) or common problem (anger management, parenting, stress reduction, or prerelease planning). Specialty groups offer a chance to work on specific issues that may be impeding other treatment initiatives or require special attention not readily available in the regular program. Two types of special- ty groups are briefly described below.

• Anger management groups. Anger manage- ment groups are widely used in drug treat- ment programs. They are especially helpful for inmates who are either passive and nonassertive or express anger in an explo- sive fashion. By careful analysis of emotion- al reactions to painful and threatening experiences, treatment staff help the inmate learn to manage anger in a more socially acceptable manner. For example, inmates may feel incapable of expressing negative feelings verbally. Instead of responding appropriately to a provocation, they allow feelings to build up, which leads to a delayed explosive reaction. Learning to express angry feelings verbally and in an appropriate manner helps inmates feel

195Treatment Issues Specific to Prisons

more competent about interpersonal rela- tionships.

• Parenting groups. Very successful groups have been organized around parenting issues. Although the perspective may differ for females and males, bonds to children can help motivate the recovery process for both genders and can contribute to a suc- cessful re-entry into the community. Practitioners have found that both men and women need to focus on developing parent- ing skills and overcoming patterns of neglect, abandonment, and abuse. As a result of parenting work, some program participants have tried to find their chil- dren and establish relationships with them upon release to the community. The process of becoming a responsible parent can be a critical component in the recovery process.

Family counseling Family therapy is a systems approach that often focuses on large family networks. Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. When possible, involvement of a family member in an indi- vidual’s treatment program can help prepare the individual for parole. Often caution needs to be exercised when involving families of offenders because of high degrees of antisocial behavior and psychological disturbance. For more information on using family therapy in substance abuse treatment see TIP 39, Substance Abuse Treatment and Family Therapy (CSAT 2004).

Individual counseling Individual counseling is an important part of substance abuse treatment. Counselors may operate from many different philosophical and theoretical orientations and employ a variety of therapeutic approaches in individu- al therapy. The common feature of such ses- sions is that inmates in a private consultation are free to explore more sensitive issues, which they might not be ready to discuss in a group. Individual sessions also provide a place where a counselor can coach inmates on relapse prevention techniques such as how to recognize specific high-risk situations, per- sonal cues, and other warning signs of relapse.

Like group counseling, individual therapy strives to help offenders develop and main- tain an enhanced self-image and accept per- sonal responsibility (CASA 1998). It can act as an important adjunct to group therapy. Additionally, skilled psychologists and social workers who offer individual therapy to offenders play a role in the development and review of a client’s treatment plan.

Self-help groups Self-help groups, found in a majority of State and Federal prisons, are frequently a crucial component of recovery and can provide a great deal of support to recovering offenders. Self-help groups provide peer support and may serve as therapeutic bridges from incar- ceration to the community.

Self-help programs were founded by individu- als who found conventional help inadequate

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The Benefits of Self-Help Groups

• Support for substance abuse treatment and recovery

•Peer support

•Healthy peer interaction

•Therapeutic bridges between the criminal justice system and the community

•Crisis prevention and management

•Personal growth

or unavailable. These individuals shared common problems and a personal commit- ment to do something about their condition. Self-help programs are not considered “ser- vices,” which require client dependence on providers. Instead, they are programs based on a philosophy of self-responsibility. The philosophy involves a powerful belief system that requires individuals to commit to their own healing. For many, this approach has proven inspiring and successful.

A major focus of the self-help approach is altering the fundamental beliefs and overall lifestyles of participants. By taking responsi- bility for their own problems, individuals can gain control over their situation and develop a new sense of self-respect and competence. Recovering role models provide support and guidance. The entire approach can result in far-reaching changes in personal lifestyles and social relationships. In general, the self- help movement successfully instills the more positive aspects of individualism—self- reliance and responsibility—while also stress- ing the importance of group effort in over- coming common problems.

The concept of empowerment is perhaps the most central to understand the positive effects of self-help groups. (For other benefits, see previous page.) Self-help processes are geared to invoke and develop a sense of personal power among members. Empowerment can be derived from a “higher power,” from the group, or entirely from within the individual, where the idea of “bottom line” responsibility for the conditions of one’s life teaches mem- bers that they have the power to alter their lives and living conditions. Self-help groups also encourage members to use their personal strength to enable others to feel less helpless. This, in turn, enhances the power of the helper. Since self-help programs are peer cen- tered, they encourage mutual support and offer many opportunities for leadership.

The best known self-help groups are Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). However, other self-help groups may be appropriate, depending on the

offender’s beliefs, needs, and interests. Other groups include Survivors of Incest Anonymous, Secular Organizations for Sobriety (SOS), religious groups, women’s groups, and veteran support groups. One sur- vey found that 74 percent of prison facilities offered self-help programs of various types. Of those, AA had the strongest representation (in 95 percent of those facilities), followed by NA (in 85 percent). Less than one third offered other types of self-help programs. Because of the lack of empirical evidence about the effectiveness of self-help programs in reducing recidivism and relapse, the con- sensus panel believes that these groups are best viewed as support activities that can enhance more structured and intense treat- ment interventions (CASA 1998).

At times compulsory self-help group atten- dance is used as a sanction. The panel feels that the compulsory use of any treatment or supportive service as a sanction is ill advised and can be detrimental to other treatment efforts. Moreover, the constitutionality of mandatory participation in spiritual-based groups has been challenged. When compulso- ry attendance is a part of the treatment, secu- lar alternatives should be made available.

Educational and vocational training Educational and vocational training, in addi- tion to attention to psychosocial and behav- ioral needs, is a critical dimension that helps offenders become responsible family mem- bers, employees, and community members. The acquisition of skills such as basic litera- cy, GED certification, and life skills can improve employment opportunities and improve self-esteem. Such enhancements also can help keep inmates from returning to sub- stance-using subcultures and ways of life. These services are generally provided by the prison and must be closely coordinated and monitored by the treatment staff as part of case management function.

197Treatment Issues Specific to Prisons

Therapeutic Techniques Specific therapeutic techniques can be especial- ly helpful in treating the prison population. As discussed below, role-playing and video feed- back can help offenders improve awareness of how others experience and perceive their behavior. Other models that have received increased attention include motivational inter- viewing, faith-based initiatives, token economy models, and the resurgence of a more tradition- al medical–pharmacological model that includes the development of medications to remove the organic effects of cocaine (i.e., craving-based treatment interventions). Typically, therapeutic techniques are not used as standalone interventions but rather blended into a treatment approach or model that addresses multiple needs with multiple tech- niques. Also, evaluation studies usually test the efficacy of program models such as the TC and rarely test the effectiveness of individual treat- ment techniques. However, the following inter- ventions have been widely used in correctional treatment and have gained clinical validity among many practitioners.

Role playing Role playing exercises have been used with incarcerated populations since the 1950s, particularly in residential treatment settings. These exercises take advantage of the fact that inmates are experienced at playing roles negatively and direct that skill toward a posi- tive end. Prior to participation in guided role playing, inmates learn the rules and purpose of this technique. This approach has been

particularly effective with perpetrators of vio- lence, as these individuals often remove them- selves emotionally from their victims. Using role play, inmates often take turns acting as both victims and perpetrators. Destructive behavior patterns, frequently rooted in child- hood, can be evoked and re-experienced. This process helps the individual understand old patterns to avoid repeating them. Roles can also be reversed so that perpetrators experience the emotions and thoughts of their victims. Habitual offenders typically feel remorse not for the crime committed but for being caught. Experience of appropriate guilt and desires to make restitution for their crimes are major goals of role playing exercises.

Video feedback Video feedback can be a valuable therapeutic tool in correctional rehabilitation. Video feed- back allows inmates to “see themselves as oth- ers see them.” For example, viewing a tape of their intake interview helps inmates cut through denial as a result of witnessing their own body postures, gestures, and facial expressions. Video sessions can also help inmates identify different behavior patterns, attitudes, and self-images. Inmates who have spent their lives on the streets may change their self-perception by seeing themselves in a video, perhaps dressed in a suit, speaking and behaving differently than before. Watching tapes of group sessions and of other activities, inmates can begin to view them- selves differently. This is especially valuable

for those with poor self-images. Inmates may have no access to visual images of themselves, since full-length mirrors are not typically available in jail or pris- ons. Lacking important informa- tion for forming an accurate self- image, an inmate’s problem may be less a matter of poor self- image than of no self-image. In such cases, videotapes can play an important role in treatment.

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Advice to the Counselor: Prison Treatment Approaches

• Treatment in prison environments should be organized according to empirically supported approaches, such as social learning, cognitive–behavioral models, skills train- ing, and family systems.

• Nondirective approaches, some medical models, and those focusing on punishment or deterrence have not been shown to be effective.

“Blended” approaches The “blended model” recognizes that a melding of different approaches and techniques can prove effective in prison-based treatment. More subtly, the corrections environment itself already incorporates a blended approach, sim- ply because the nature of prisons requires adaptation of existing structural and security concerns.

Blended approaches expand in-prison treat- ment offerings to include more innovative techniques and treatment modalities. These require creativity, the imaginative use of available resources, proper identification of inmate problem severity (i.e., the more severe the inmate’s problem, the more intensive the treatment services), support for program- ming, adequate physical plant and design, attention to the impact of activities on classifi- cation and movement, cost, monitoring, and continued professional development of cor- rectional staff.

One example of a blended approach program is the Residential Substance Abuse Treatment located at the South Idaho Correctional Institution. It offers a combination of three treatment strategies, including cognitive– behavioral and 12-Step programming set within a TC (Stohr et al. 2001). A unique fea- ture is its target population: parole violators who abuse substances. Using qualitative and quantitative data collection techniques, an initial evaluation team determined it to be sound in content and service delivery.

In-Prison Therapeutic Communities Offshoots of the mental health and self-help approaches, TCs are among the most success- ful in-prison treatment programs. Because of the intensity of treatment, TCs are preferable for the placement of offenders who are assessed as substance dependent. The Federal Bureau of Prisons and State systems in California, Delaware, New York, Oregon, and

Texas, among others, have well-established TC programs in place.

Surveys of the membership of Therapeutic Communities of America (Melnick and DeLeon 1999) and the residential TC pro- grams in the Drug Abuse Treatment Outcome Survey (De Leon 2000; Melnick and De Leon 1999) show high levels of agreement among TCs as to the nature of the essential treat- ment elements including the treatment approach, the role of the community as a therapeutic agent, the use of educational and work activities, the formal elements of TC treatment, and the TC process. The stan- dards have undergone field testing conducted by the Therapeutic Communities of America and the Office of National Drug Control Policy. The more than 120 revised standards cover 11 domains, from theoretical basis and administration to staffing, stages of treat- ment, and aftercare. These are available at www.whitehousedrugpolicy.gov/national_ assembly/publications/therap_comm/therap_ comm.pdf.

Goals The core beliefs and practices of the TC have been described in the literature (Bell 1994; De Leon and Rosenthal 1989; De Leon 1997, 2000; Kooyman 1986; Sugarman 1986; Wexler 1995; Wexler and Williams 1986). The general goals of TCs are (1) decline in or abstinence from substance use, (2) cessation of criminal behavior, (3) employment and/or school enrollment, and (4) successful social adjustment. Prison TCs maintain a high level of control over their participants, and treat- ment goals are always secondary to security.

Structure Although there is some variation in the struc- ture of these programs, most are a minimum of 6 months in duration and consist of three or four stages:

• Orientation to acquaint inmates with the rules of the TC and establish routines

199Treatment Issues Specific to Prisons

• Group and individual counseling to work on issues of recovery

• Maintaining recovery and relapse prevention

• Reentry planning (Peters and Steinberg 2000)

There is also evidence that prison-based TC programs may provide their best results for those whose residency extends from 9 to 12 months (Wexler et al. 1990). Relapse can be relatively high, however, if there is no conti- nuity of care provided after release from cus- tody. Research has clearly shown that after- care in the community is essential to prevent relapse and recidivism (Knight et al. 1999b; Martin et al. 1999; Wexler et al. 1999a). One study found that offenders who were in treat- ment for 12 to 15 months while in prison, combined with 6 months of aftercare, were more than twice as likely to be drug-free 18 months after release than offenders who received prison-based treatment alone (Inciardi 1996). Offenders who receive after- care are also less likely to be rearrested in the 18 months after their release than offenders who receive only in-prison treatment (71 and 48 percent, respectively).

Components The TC’s daily regimen involves the resident in a variety of work, educational, therapeutic, recreational, and community activities. Main program components are

• Community meetings, events, and ceremonies

• Seminars

• Group encounters

• Group therapy

• Individual counseling (both from staff and peers)

• Tutorial learning sessions

• Remedial and formal education classes

• Client job-work responsibilities

• Explicit treatment phases that are designed to provide incremental degrees of psychological and social learning

TCs differ from self-help groups, such as AA, in that they are structured, hierarchical, and highly intense intervention programs while AA provides peer support only. The TC treat- ment experience promotes a sense of cama- raderie, safety, and communication as keys to transformation from degradation to dignity. One of the most complex treatment models to implement and operate in a prison, TCs require significant changes in the norms, val-

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Program Elements of a TC

Rod Mullen, founder of the Amity prison TC program, has attempted to define the program elements need- ed for a TC and suggests that programs that do not meet this standard be identified simply as “residential” to avoid indiscriminate use of the TC identification:

• Twenty-five to 50 percent of the staff should have a substance abuse history and at least 2 years of contin- ual sobriety.

• The program must emphasize peer leadership and a structure of peer responsibilities and authority.

• The program must have a defined structure of community ceremonies that occur daily (as well as at other intervals), which reinforce the beliefs and mission of the community.

• Regular encounter groups are held for all participants and confidentiality of the group is a paramount community value.

• All staff members participate in community activities.

• The emphasis of the community is on the healthy, positive development of all aspects of its members.

ues, and culture of the environment and a great deal of commitment and cooperation from prison administration and staff to prop- erly structure and control that environment.

While residents must take responsibility for their own recovery process, treatment staff, including ex-offenders, act as role models and provide support and guidance. Individual counseling, encounter groups, peer pressure, role models, and a system of incentives and sanctions form the core of treatment interven- tions in a TC. Residents of the community must live together, participate in groups, and study together. In the process, inmates learn to control their behavior, become more hon- est with themselves and others, and develop self-reliance and responsibility.

TCs are most often implemented in a residen- tial structure isolated from the general popu- lation to provide enough safety and sense of belonging to begin the process of change. States of anxiety, secrecy, fear, and alien- ation—conditions permeating the antisocial inmate subculture of the general prison popu- lation—are antithetical to positive change. In fact, separation from the prison subculture during treatment has been found to be most conducive to achieving major changes in atti- tudes and behavior. However, the safe TC environment, coupled with gains in interper- sonal skills, helps offenders relate to the gen- eral prison population with the inner strength needed to combat the negative cues of the prison environment.

Practitioners note that there can be no “watchers” in a TC, only active participants. TCs demand the participation of the inmates in the emotional, physical, and intellectual work required for the process of change and personal growth. Work in a TC, as a part of treatment, involves an increasing set of responsibilities designed to build self-confi- dence and coping skills. As active participants in their own recovery process, inmates learn self-sufficiency and competence. Practitioners often cite an old maxim that captures the

essence of the TC philosophy: “Give people a fish and they have food for a day. Teach them to fish and they can obtain food for a life- time.”

TCs depend on the staff and participants’ community-building capabilities. The degree and intensity of confrontation with partici- pants tends to correspond to the strength of the supportive atmosphere of the program. Confrontation in prison, for example, may be less intense than in a community-based envi- ronment, since confrontation can be a threat to prisoner codes of acceptable behavior. The success of the TC also depends on the collabo- ration between treatment and corrections staff in classification of inmates who are appropriately assessed and placed in treat- ment as well as in the delivery of sanctions and removal from the treatment unit.

Successful Prison-Based TC Programs The TC is widely recognized as an effective approach that is highly intensive in nature and scope, deals effectively with issues related to implementation and maintenance, and address- es many of the more important treatment issues. Some examples of successful in-prison TC programs are described below along with references that provide further information.

Stay’n Out in New York The Stay’n Out program was implemented in July 1977 as a modified hierarchical TC. Stay’n Out began at a time when many other in-prison TC programs were closing. Program capacity was 120 inmates at the time this research was conducted. Residents lived in two housing units segregated from the rest of the prison population. They had contact with prisoners in the general population only when off the TC unit (e.g., at the cafeteria, infir- mary, library). The Stay’n Out staff com- prised mostly persons in recovery with TC experience.

201Treatment Issues Specific to Prisons

The results of a 3-year outcome study of the Stay’n Out prison TC indicate that this pro- gram is effective in reducing recidivism rates (Wexler et al. 1988, 1990). As summarized in Figure 9-3, program completion also decreased the likelihood of rearrest.

Research also found a strong relationship between time spent in the program and treat- ment outcomes. For male inmates who partic- ipated in Stay’n Out, the percentage of those who had no parole infractions during commu- nity supervision rose from 50 percent for those who remained less than 3 months, to almost 80 percent for parolees who were in the program between 9 and 12 months while in prison. Similar findings were obtained for the females, although the percentages of those discharged positively from parole were higher than for their male counterparts (79 percent for females in treatment less than 3 months, 92 percent for the 9 to 12 month group) (Wexler et al. 1988, 1990).

Delaware KEY-CREST programs The KEY-CREST programs, evaluated by the Center for Drug and Alcohol Studies at the University of Delaware, represent a treatment continuum that mirrors the offenders’ cus- tody status (Inciardi et al. 1997). Prisoners with a history of drug-related problems are identified and referred to the KEY TC pro- gram. Following prison release, parolees then go to the CREST program, a TC-based work- release program. Six-month postrelease relapse and recidivism rates for graduates of

both KEY and CREST were significantly lower than for program dropouts and a non- treatment comparison group (Martin et al. 1995; Nielsen et al. 1996). A followup study at 18 months showed that among those who com- pleted both the prison-based and the work- release aftercare programs, fewer used drugs and were rearrested compared with an untreated comparison group (Inciardi et al. 1997). Outcomes at 3 years were similar, although somewhat attenuated (Martin et al. 1999). A recent study by the Delaware Sentencing Accountability Commission has confirmed the positive results (SENTAC 2002).

Amity prison TC Originally established as a demonstration project funded by the California Department of Corrections in 1989, the Amity TC is locat- ed at R.J. Donovan Correctional Facility in San Diego, a medium security prison. (See Graham and Wexler 1997 and Winnett et al. 1992 for detailed program descriptions.) The prison houses approximately 4,000 men in five self-contained living areas. All aspects of daily living (e.g., housing, education, work, etc.) are accommodated within the confines of the prison. One 200-man housing unit is des- ignated for Amity project occupancy. The men residing in the unit participate in daily programming conducted in two trailers locat- ed near the housing unit.

The program uses a three-phase treatment process (DeLeon 1995; DeLeon and Rosenthal 1989; Wexler and Williams 1986). The initial

202 Chapter 9

Figure 9-3

Stay’n Out Program Outcomes

Rearrest

Male Graduates Males with No Treatment

Femate Graduates Females with No Treatment

27 percent 41 percent 18 percent 24 percent

Source: Wexler et al. 1988, 1990.

phase (2 to 3 months) includes orientation, clinical assessment of resident needs and problem areas, and planning interventions and treatment goals. Most residents are assigned to prison industry jobs and given limited responsibility for the maintenance of the TC. During the second phase of treatment (5 to 6 months), residents are provided opportunities to earn positions of increased responsibility by showing greater involvement in the program and by focusing on emotional issues. Encounter groups and counseling ses- sions address self-discipline, self-worth, self- awareness, respect for authority, and accep- tance of guidance for problem areas. During the reentry phase (1 to 3 months), residents strengthen their planning and decisionmaking skills and work with program and parole staff to prepare for their return to the community.

Upon release from prison, graduates of the Amity prison TC may elect to participate in a community-based TC treatment program for up to 1 year. Residents at this Amity Aftercare TC have responsibility for main- taining this facility (under staff supervision) and continuing the program curriculum. The aftercare TC also provides services for the wives and children of residents.

An evaluation conducted by the Center for Therapeutic Research at the National Development and Research Institutes, Inc., assessed 36-month recidivism outcomes for a prison TC program with aftercare using an intent-to-treat design with random assign- ment. Outcomes for 478 felons at 36 months replicated findings of an earlier report on 12- and 24-month outcomes, showing the best outcomes for those who completed both in- prison and aftercare TC programs (Wexler et al. 1999a). For those who completed the TC aftercare program, 27 percent had been rein- carcerated at a 36-month followup, compared to 75 percent for the other groups. Researchers also noted a significant positive relationship between the amount of time spent in treatment and the time until return for the parolees who recidivated. However, the reduced recidivism rates for in-prison treat-

ment at 12 and 24 months were not main- tained at 36 months (Wexler et al. 1999b).

Texas Kyle New Vision Program The Kyle New Vision program was the first in-prison TC (ITC) developed under 1991 State legislation that outlined plans for sever- al corrections-based substance abuse treat- ment facilities in Texas (Eisenberg and Fabelo 1996). It is a 500-bed facility that provides treatment to inmates during their final 9 months in prison. After release, parolees are mandated to attend 3 months of residential aftercare in a transitional TC (TTC), followed by up to another year of supervised outpa- tient aftercare. An evaluation conducted by the Institute for Behavioral Research at Texas Christian University revealed that 3 percent of those who completed both ITC and TTC programs were rearrested within 6 months of their release from prison, com- pared to 15 percent of those who only com- pleted the ITC and 16 percent of an untreat- ed comparison group (Knight et al. 1997). Furthermore, results from hair specimens collected during a 6-month followup indicated that fewer of those who completed both the ITC and TTC tested positive for cocaine (the primary drug of choice for those in the sam- ple), compared to those who completed only the ITC and a comparison group (Knight et al. 1998). A recently completed study showed that TTC completion following the ITC was the strongest predictor of remaining arrest- free for 2 years following release from prison. Aftercare completion was strongly associated with parolee success (Hiller et al. 1999a). A 3- year outcome study revealed that high-severi- ty aftercare completers recidivated only half as often as those in the aftercare dropout and comparison groups. These results indicate that intensive treatment can be effective when it is integrated with aftercare and that the benefits of intensive treatment are most apparent for offenders with more serious crime and drug-related problems (Knight et al. 1999b).

203Treatment Issues Specific to Prisons

Federal Bureau of Prisons While not technically a TC program, the Federal Bureau of Prisons offers voluntary residential treatment programs, or Drug Abuse Programs (DAPs), for alcohol and drug problems that use some of the features of the TC model. Inmates participate in a total of 500 hours of treatment over a 9- month period and programs have 1 staff member for every 24 inmates. Program goals are to identify, confront, and alter the atti- tudes, values, and thinking patterns that led to criminal behavior and substance abuse. This is accomplished through a unit-based approach (whereby program participants are segregated from the general population to build a treatment community), and also through standardized program content that includes 450 hours of programming using modules devoted to a variety of subject areas. Though initially implemented without incen- tives, the passage of time saw the introduction of financial achievement awards; considera- tion for a full 6 months in a halfway house for successful DAP program completion; and tan- gible benefits such as shirts, caps, and pens with program logos. The passage of the Violent Crime Control and Law Enforcement Act of 1994 allowed eligible inmates with suc- cessful completion rates to reduce as much as a year from their statutory release dates.

The second component is graduate mainte- nance, an 8-week program for those who com- pleted the initial component. Skills are rein- forced from the first component and transi- tion plans are initiated. The third and final component, aftercare, provides services from completion of graduate maintenance to release from department custody. This com- ponent attempts to reinforce attitudinal and behavioral changes that occurred during the first three phases. Transition plans are regu- larly reviewed, placements for inmates in community-based programs are completed, and tracking occurs for all inmates at regular intervals.

Specific Populations in Prisons

Co-Occurring Substance Use and Other Mental Disorders Despite the high incidence of co-occurring mental and substance use disorders, few pro- grams for inmates with co-occurring mental and substance use disorders currently oper- ate in prisons. Edens and colleagues (1997) found fewer than 10 operational programs that were designed for this population (see next page for a description of one such pro- gram), although several State correctional systems reported that similar programs were being planned. A number of common ele- ments of these programs included phased pro- gram interventions, a focus on destigmatizing mental disorders, the use of psychoeducation- al interventions, involvement of mental health staff in major program activities, and the use of relapse prevention approaches.

Sex Offenders In 1999, nearly 9 percent, or 100,800, of the 1.2 million inmates in State prisons were incarcerated on sex-related offenses: 2.6 per- cent (29,600) for rape and 6.2 percent (71,200) for other sexual assault (Burdon et al. 2001). Among incarcerated sex offenders, two of every three have a history of alcohol or substance use, abuse, or dependence (Peugh and Belenko 2001).

Given their prevalence in the prison popula- tion, as well as the high rate of substance abuse, in-prison substance abuse treatment programs are likely to be treating a number of sex offenders. Burdon and colleagues (2001) identified several barriers to successful treatment of sex offenders in correctional institutions:

• Stigma. Sex offenders are perceived as occupying the lowest possible rung within the prison social hierarchy, not only among inmates, but also among custodial and often

204 Chapter 9

treatment staff. This leads to extreme secre- cy and fear of self-disclosure based on a legitimate fear for their own safety.

• Untrained and inexperienced staff. Most treatment staff members in prison-based substance abuse programs lack the requisite knowledge to work effectively with sex offenders. This can be remedied in part by recruiting and hiring individuals with advanced degrees or special certification, although it will entail increased treatment costs associated with compensation to ensure their longevity.

• Institutional policies against disclosure. Strict prohibitions against disclosing inmate offense and conviction information means that staff are unable to identify which inmates are sex offenders.

• Lack of a formal process for identifying clinical sex offenders. The different classifi- cations of those who have committed sex- related offenses and those diagnosed with sex-related disorders makes identification more difficult for providers. Currently, the sole criterion for identification is the inmate’s criminal record. Because some individuals are likely to be recommended for highly specialized treatment and may not need it, this criterion may result in an inefficient use of resources.

One proposed model is to provide effective treatment by differentiating between legal and clinical offenders and then offering treatment to clinical sex offenders. Steps in this process include identifying those sex offenders suit- able for treatment, identifying the appropri-

205Treatment Issues Specific to Prisons

San Carlos Correctional Facility—A TC Modified for Offenders With Mental Illness

In response to the increasing number of inmates with co-occurring substance use and other mental dis- orders, the Colorado Department of Corrections contracted with a private not-for-profit agency to develop the Personal Reflections Therapeutic Community program at the San Carlos Correctional Facility in Pueblo (Sacks et al. 2001). Based on evidence of the effectiveness of the TC approach for co- occurring disorders implemented in a community-based setting (De Leon et al. 2000), the San Carlos program, a Modified Therapeutic Community (MTC), uses TC principles and methods as the foundation for recovery. Modifications from traditional TCs include smaller caseloads, shortened and simplified meetings, and minimized confrontation. In addition, the MTC contains components to address criminal thinking and to provide medication education.

The goal of the program is to use a positive peer culture to foster personal change and to reduce the incidence of return to a criminal lifestyle. The inmates progress through program stages, typically mov- ing from orientation to primary treatment (“family” phase) and then preparation for re-entry to the community at large. Upper level inmates in the MTC program function as a positive peer leadership group, or “structure,” to guide and support newer members as they begin to develop and apply new val- ues, beliefs, and skills to their daily lives. Thus the San Carlos TC, modified for the mentally ill popula- tion, functions as a healthy family for its members, reinforcing affiliation with the recovery community.

A NIDA-funded evaluation of MTCs showed significantly better outcomes on self-reported crime and arrests for the MTC group as compared to standard mental health and nontreatment groups. The best outcome was for the MTC group that also received TC aftercare. In response to such results, a CSAT Community Action grant supported an initiative to improve services for released offenders with histories of substance abuse and severe and persistent mental illness (Wexler 2001). Preliminary cost analysis indicates that the incremental (or additional) costs of prison MTC programs for offenders with co-occur- ring disorders are low compared to both the overall costs of incarceration and the additional cost of ser- vices for people with co-occurring disorders in the general prison population (Sacks et al. 2001).

ate treatment modality, and maximizing suc- cess by providing needed aftercare (Burdon et al. 2001). More detailed information on sex offenders is in chapter 5, Major Treatment Issues and Approaches.

Older Inmates In recent years, the number of inmates in State and Federal prisons aged 55 and older has increased dramatically. Between 1995 and 2003 that number has increased approximate- ly 85 percent, so that as of 2004 there were 27,700 prison inmates over the age of 55 (Harrison and Beck 2004). Many, though not all, of these inmates have spent much of their lives in prison. The 1994 Crime Bill ratifying the “three strikes and you’re out” provision could increase these numbers substantially as it becomes a more fully utilized sentencing option.

As a distinct cultural subgroup, lifers have spent much of their adulthood in “total insti- tution” environments with unique features. Among them are the physical barriers to the outside world, the development of a unique way of life, or “prison culture,” which pre- cludes “normal” interactions and social activ- ities found on the “outside.” This stressful, unnatural situation can produce what Goffman (1961) termed “disculturation,” wherein prison rules and mores have out- weighed those of the outside world. Over pro- longed periods, the implications for inmate self-concept and autonomy may be more pro- nounced.

Additional “disculturative” changes can occur relating to family, employment, and sexual identity. Although all inmates face these chal- lenges upon incarceration, the aging inmate faces the imminent probability that a tradi- tional life cycle will be seriously altered. “Time that might have been spent in

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Use of “Lifers” as Peer Counselors at Amity

In 1990, the Amity prison TC at the R.J. Donovan Correctional Facility, a medium security facility, began to accept offenders who were under life sentences (i.e., “lifers”) as counselors in its substance abuse treat- ment program. It remains one of a handful of programs in the country to do so.

Lifers were accepted as members of the counseling staff because they could provide stability to the pro- gram and ensure its continuity. They are available to program participants 24 hours a day, unlike staff from outside the prison, and can have a vital role in keeping a community alive and helping to hold its members responsible for their behavior. Because these are individuals who have considerable respect in the prison community, they are able to help keep participants in the program safe and out of situations that can cause them trouble.

The program is selective about who can become a counselor; all counselors have to be graduates of the program and then complete a 2-year internship. They must be individuals who have the respect of their peers and demonstrate high levels of motivation. The program also ensures that this group represents the racial demographics of the prison population.

Programs that are considering using lifers should already have trained staff who are experienced work- ing with this particular subpopulation. The culture of lifers is unique within the prison system, and the problems they face are also often different. These are individuals whose home, for much (if not all) of the rest of their lives is the prison. Becoming a counselor enables lifers to make personal restitution for past acts by helping others, which they may never have the opportunity to do so outside the prison envi- ronment. During followup interviews, many of the successful program participants mentioned that lifers had been important influences in their recovery (Wexler et al. 1999a).

courtship, marriage, raising children, career, education, travel, pursuit of personal talents, and activities with friends never can be re- established” (LaMere et al. 1996, p. 27). The usual milestones to measure success and adult rites of passage are systematically denied the aging inmate, thus producing a sense of social disconnection. One of the best ways to engage elderly inmates is to involve them in helping other inmates. The program at the R.J. Donovan Correctional Facility (see previous page) is an example of a treatment approach that can be beneficial to both the aging prison population and its younger peers.

Systems Issues

Coerced Treatment In prison, coerced treatment may come as a result of a sentence mandating treatment or as a result of a prison policy mandating treat- ment for inmates identified as having sub- stance use disorders. Still, prison-based pro- grams generally do not have significant incen- tives for parolees or probationers who enter treatment as a means to avoid prison. Research indicates that treatment adherence and outcomes are the same among those coerced into treatment and those who entered treatment voluntarily (Miller and Flaherty 2000). In terms of prison-based treatment programs, Wexler and colleagues (1996) reported that these programs are often the only (emphasis added) treatment opportuni- ties for offenders. Two key issues regarding treatment of offenders are time spent in treat- ment and engagement in the process. Coerced treatment can force inmates to begin a treat- ment episode, but the program must be able to engage them in a meaningful rehabilitation process. The longer the inmate remains in treatment, the greater the likelihood for suc- cess (Hubbard et al. 1988; Simpson 1984; Wexler 1988). Without treatment, the likeli- hood of continued drug use and criminality after release increases considerably (Lipton 1994).

Sanctions and Incentives A hierarchy of specific sanctions (that notes the type and duration of each sanction) can be used in conjunction with treatment incen- tives and rewards to improve treatment out- comes. TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (CSAT 1994a), gives a more detailed overview of sanctions and their effective use.

Offenders need to be responsible to their indi- vidual treatment plans and held accountable to the treatment program’s rules. They must know the consequences of noncompliance and poor progress and understand that treatment programs have certain unbreakable or “car- dinal” rules (e.g., no violence or intimida- tion). The penalties for breaking rules that are intended to guide behavior can include dismissal from the program or revocation of privileges. Sanctions should be applied con- sistently for positive drug tests, no-shows for treatment, prohibited behavior, or broken program rules. Penalties should be specifical- ly spelled out, so there is no doubt in the client’s mind regarding the consequences of specific misbehavior. Accountability also includes objective measures and monitoring as a basis for measuring the client’s progress and determining the need for reassessment. Rule infractions (other than “cardinal rules”) are best seen as opportunities to learn more appropriate and effective behaviors. This treatment or learning perspective is in con- trast to the traditional correctional view of adjudication and punishment. It is important to provide opportunities for “failed” clients to reapply to the program when possible. Often, a program failure can be a learning experi- ence that leads to increased motivation and desire for a “second chance.” Given that addiction is a chronic, recurring condition, multiple treatment episodes are more the norm than the exception.

Just as sanctions clearly establish a series of consequences for designated behaviors, incen- tives should be offered to inmates who adhere

207Treatment Issues Specific to Prisons

to the program rules, to recognize small accomplishments. Possible incentives include:

• Recognition ceremonies

• Awards

• Preferred meals

• Special desserts

• T-shirts, coffee mugs, or other small gifts

• Modified uniforms (which contributes to a positive environment)

• Deviations from the standard curriculum including seminars, music, and sports

• Financial rewards

• Increased privileges

• Safe housing units

• Additional recreation time

• Positive parole board review

• Return of children to their mothers

Wherever possible, problems of attrition and noncompliance should be anticipated early enough in the treatment process to avert them. The panel believes that coordination and communication between the treatment counselor and criminal justice staff are cru- cial in this process. For example, the treat- ment counselor can use a proactive attitude and alert the criminal justice representative when noncompliance occurs, long before a client is actually expelled from a program, if it appears that a situation leading to this out- come is developing. It is also helpful if the treatment counselor and criminal justice rep- resentative discuss certain general trends in advance. Such particulars as retention rates, the most likely dropout points, and relapse rates in various stages of treatment can be used to alert case managers in other systems to potential problem periods and when they are likely to occur.

Disincentives for Inmate Participation Despite these incentives, there are factors— both perceived by the inmate and inherent in the system—that the panel believes may dis-

courage involvement in a residential treatment program:

• Increased surveillance on the job and in the treatment program. This includes the justi- fication for increased urinalysis during treatment and posttreatment phases.

• The requirement and pressure to stop using drugs. Although prevalence levels are lower in prison than the general population, there is still substance use and when enrolled in treatment, the offender must confront the necessity of having to stop using drugs.

• Loss of relationships. Women especially may resist treatment because they have the per- ception that participation could result in the loss of in-prison intimate relationships.

• Loss of income. Often it is a requirement to give up prison jobs in order to enter treat- ment.

• Peer (or yard) pressure. Offenders can face physical threats of violence if they partici- pate in treatment.

• Lack of treatment continuum. Intensive treatment inside the prison is of limited use if there are no services available upon release. Furthermore, it is critically impor- tant to build upon previous treatment rather than forcing a newly released inmate graduate to start over in the community program.

• Treatment length and modality. If treat- ment is not linked to inmates’ needs, inmates are more likely to drop out. For example, often an offender who has serious substance abuse problems and is in need of a structured environment is placed in a 12- Step program on a voluntary basis, whereas a person who only occasionally uses sub- stances is inappropriately placed in a long- term TC or other residential program.

• Lack of desire to help one another. For many offenders, the key to doing prison time is to get through it without any extra output of energy to help others (e.g., “I’m doing my time. I’m not doing his time.”). It is not selfishness per se but rather part of prison culture.

208 Chapter 9

• Limited treatment resources. There are often problems associated with convincing inmates to engage in treatment. One prob- lem is the lack of trained staff and available modalities. Additionally, treatment pro- grams often do not offer incentives. In fact, some incentives (e.g., work furloughs) are removed, which acts as a disincentive to enter treatment.

• Stigma. Many inmates want treatment, but do not necessarily want to be put in pro- grams that may cause them to have low sta- tus in the inmate culture.

• Mandatory sentences that prohibit early release. Increasingly, in an effort to appear ever tougher on crime, politicians and poli- cymakers are removing early release oppor- tunities by legislating mandatory sentences that require inmates to serve their full terms, reducing or eliminating good time credits, or being more stringent in Parole Board decisions. Without the incentive of early release, inmates are less likely to vol- untarily enter and remain in prison treat- ment programs.

Staff Training and Cross-Training Cross-training for both criminal justice and substance abuse treatment staff can improve the effectiveness of program administration (Farabee et al. 1999). Treatment providers and custody staff often become familiar with the philosophy, approach, goals, objectives, language, and boundaries of both systems.

The consensus panel encourages treatment providers to under- stand the operational responsibili- ties of the justice system, the importance of public safety, and the security concerns that are at the heart of criminal justice. Criminal justice personnel should understand the dynamics of sub- stance abuse treatment and its potential to reduce recidivism and relapse. Without these training safeguards in place, the custody

concerns of the correctional facility will often overwhelm the concerns of the treatment pro- gram (Farabee et al. 1999). Some of the train- ing issues include confidentiality, relapse pre- vention, infectious diseases, co-occurring dis- orders, and cultural competence.

Other concerns regarding recruitment and training of staff include the difficulty of hir- ing qualified staff in the remote areas where prisons are built; the lack of experience in criminal justice settings on the part of most counselors; and the perennial concern about high turnover rates and the lack of experi- enced counselors, especially given the limited ability to hire individuals in recovery as counselors (Farabee et al. 1999). In addition, Department of Corrections contracts fre- quently have restrictions based on criminal history that narrow the eligible pool of employment applicants.

Gender-specific training The panel stresses that training should review the latest theories and findings on men’s and women’s issues in treatment. For counselors working with men, special focus should be on anger management and relational violence. Staff should learn theories of male develop- ment and explore key issues influencing men’s substance abuse—societal gender roles, fami- ly, relationships, rage and violence, abuse and trauma, and educational and vocational issues. In addition, staff need to become familiar with the prison culture specific to the

209Treatment Issues Specific to Prisons

Advice to the Counselor: Heading Off Noncompliance

• Counselors can take a proactive attitude and alert the criminal justice representative when noncompliance occurs before a client is expelled from a program.

• The treatment counselor and criminal justice representa- tive can identify the most likely program dropout points to alert case managers to potential problems in the system.

program’s geographic location, for example, race and gang issues, “the convict code,” and prison slang. Knowledge and understanding about these issues ensures greater impact and provides staff deeper insight into incarcerated men’s barriers to recovery.

Staff working with incarcerated women should be familiar with theories of female development and consider ways that treat- ment programs can address the central importance of relationships for women.

Training should also explore key issues influencing women’s substance abuse— family, parenting, relationships, self- sufficiency and life skills, anxiety and depression, grief and loss, abuse and trauma, educational and vocational issues, and societal gender roles. Expertise in these areas will help develop a quality program focused on helping incarcerated women recover and successfully re-enter their communities.

Further information on gender training is

in chapter 6. Two forthcoming TIPs will also provide detailed information on gender train- ing, Substance Abuse Treatment and Men’s Issues (CSAT in development f) and Substance Abuse Treatment: Addressing the Specific Needs of Women (CSAT in develop- ment g).

Recommendations and Further Research The following are the consensus panel’s recom- mendations regarding treatment in prisons:

Recommendations • In-prison treatment for substance abuse can

reduce recidivism.

• In general, treatment programs based on social learning, cognitive–behavioral mod- els, skills training, and family systems approaches are more effective than nondi- rective programs or those using punishment or deterrence.

• Successful programs provide a variety of intensive services that use several approaches and create a prosocial environ- ment.

• Nine to 12 months of treatment in a TC is the recommended duration for reducing recidivism, although a noticeable improve- ment in recidivism is noted after 3 months.

• To sustain the gains achieved in in-prison TCs requires supervision in an aftercare program in the community.

• TCs can be adapted to make them more appropriate for female inmates.

• Quality assurance models are needed for assessing prison treatment.

• The needs of incarcerated women (and their children) have to be better understood, with an emphasis on reintegrating the fami- ly when appropriate and developing mar- ketable skills.

• As the number of people with co-existing substance use and other mental disorders in prisons expands, treatment models that integrate the best mental health and sub- stance abuse treatment practices need to be developed and tested.

• The mental health and substance abuse lit- erature on co-occurring disorders has iden- tified the modified TC as a promising treat- ment model.

210 Chapter 9

Criminal justice

personnel should

understand the

dynamics of

substance abuse

treatment and its

potential to

reduce recidivism

and relapse.

• Issues of aftercare and continuity of care are especially relevant to offenders with co- occurring disorders, who are particularly in need of continuing treatment to stabilize their positive gains and to promote integra- tion with the mainstream community.

• Restructuring the prison environment to address education and employment, partic- ularly for inmates with longer sentences, can dramatically improve prison security, programming, and outcomes.

• Providers should develop innovative after- care programs that incorporate recovery, employment, and educational best practice. Continuity of vocational goals should be identified early on and followed throughout the various phases of client reintegration from prison to community residential and aftercare outpatient treatment.

Further Research In-prison substance abuse treatment, particu- larly when followed by community-based con- tinuing care, has been credited with reducing short-term recidivism and relapse rates among offenders who are involved with illicit drugs. More recently, the sustained effects on longer-term outcomes have been documented by studies conducted in California, Delaware, and Texas. There is a growing credibility of the idea that “treatment works,” which is replacing the older belief that “nothing works” in prison rehabilitation.

However, the benefits of treatment can vary greatly depending on the inmate being treated and the services being provided. The consen- sus panel believes it is critical that research now focus on determining which inmates ben- efit the most from the different types of treat- ment programs being offered in prison. For example, should intensive treatment pro- grams such as TCs give admission priority to inmates with the most severe problems? Are better educated inmates best treated with a cognitive–behavioral approach? Is it better to develop stand-alone in-prison treatment facil- ities?

There is considerable research that shows that at least 3 months of community treat- ment and 9–12 months of prison treatment are needed to produce significant improve- ment and reductions in recidivism and relapse. The critical need for adequate treat- ment duration has been demonstrated. What is not known is whether postprison treatment alone can be effective and how much time in aftercare following prison treatment is need- ed. Currently, in-prison drug treatment pro- grams vary considerably in length: from 4 months to 2 years. Also, given the importance of aftercare, can similar outcomes be obtained with a shorter duration in-prison treatment program if inmates are mandated to a comprehensive postrelease aftercare pro- gram?

Treatment and aftercare research questions • A clear understanding of the treatment

“black box” remains elusive; models that describe effective treatment processes need to be developed and tested.

• The organizational and system dimensions of treatment need to be studied and under- stood to foster the implementation and maintenance of treatment networks within complex correctional systems.

• Researchers should examine the contribu- tion of pharmacotherapy to treatment out- comes among prisoners.

• Although prison evaluation studies of women have shown positive treatment effects, more research is needed to study treatment engagement, process, and costs versus benefits for this population.

• Consideration needs to be given as to whether aftercare alone is capable of signif- icantly reducing recidivism and relapse fol- lowing prison.

• Researchers should investigate the effect of shorter term prison treatment with and without aftercare.

211Treatment Issues Specific to Prisons

• Researchers should consider the optimum combination of duration of both in-prison and aftercare treatment.

• Researchers need to determine what the best treatment models are for dealing with the inherent geographic dispersion of offenders after their release from prison.

• Research is needed to evaluate the costs and cost-benefits of prison treatment and after- care.

212 Chapter 9

213

10 Treatment for Offenders Under Community Supervision

In This Chapter…

The Population

Levels of Supervision

Treatment Levels and Treatment Components

What Treatment Services Can Reasonably Be Provided for People Under Community

Supervision?

Treatment Issues for People Under Community

Supervision

Treatment Issues Specific to People on Parole

Treatment Issues Specific to Probationers

Strategies for Improving System Collaboration

Sample Programs

Conclusions and Recommendations

Overview Substance abuse treatment for parolees and probationers differs from treatment for people in jail or prison. Although their freedom is cur- tailed, they have greater access to drugs and alcohol than the incarcer- ated population, and hence more opportunities to relapse. Moreover, securing basic needs such as food and shelter is often of paramount importance, especially for parolees attempting to reintegrate into society.

After describing the population under discussion in this chapter, the text takes up levels of supervision and treatment. Next, the discussion provides a broad look at the services needed by probationers and parolees and examines the treatment issues that are specific to offenders under community supervision. The chapter then suggests strategies that are helpful in improving collaboration between the substance abuse treatment and criminal justice systems. Finally, the chapter presents descriptions of sample programs.

The offenders discussed in this chapter also are discussed elsewhere in the TIP. Probationers, for example, are often sentenced through the drug courts described in chapter 7, Treatment Issues in Pretrial and Diversion Settings. Indeed, much of the material in chapter 7 is applica- ble to the probation population. Many probationers also have spent time in jail, as discussed in chapter 8, Treatment Issues Specific to Jails. Chapter 9, Treatment Issues Specific to Prisons, describes the prison culture that parolees left upon release. In order to acquire an understanding of the full range of issues that affect the treatment of offenders under community supervision, the reader is advised to con- sult these other relevant chapters.

The Population Both parolees and probationers are under com- munity supervision; nonetheless, they repre- sent different ends of the criminal justice con- tinuum. Whereas parolees and mandatory releasees are serving a term of conditional supervised release following a prison term, pro- bationers are under community supervision instead of a prison or jail term.

Despite their differences, parolees and proba- tioners often share a history of drug or alco- hol use. Approximately two thirds of proba- tioners can be characterized as alcohol- or drug-involved offenders (Mumola and Bonczar 1998), while almost 74 percent of State prisoners expected to be released between 2000 and 2001 were drug- or alcohol- involved (Beck 2000c). Parolees and proba- tioners also are alike in that their freedom is conditional; both groups must meet certain conditions in order to avoid incarceration or reincarceration. Often, treatment for drug or alcohol dependence is one of those conditions.

The number of people under community supervision has increased over the past decade. More than 4.8 million individuals were under community supervision in 2003, compared to 3.8 million in 1995. The parole population has been the slowest growing since 1995, with an average annual rate of 1.7 per- cent; however between 2002 and 2003, the growth rate nearly doubled to 3.1 percent (Glaze and Palla 2004).

Despite the shared experience of individuals under community supervision, as Figure 10-1 indicates, parolees and probationers differ considerably.

Levels of Supervision While both probationers and parolees are under community supervision, the level of supervision varies according to individual cir- cumstances. These differences are described below.

Intensive Supervision Intensive supervision generally involves fre- quent contact with supervising officers, fre- quent random drug testing, strict enforce- ment of probation or parole conditions, and community service. The level and type of supervision that are labeled intensive vary widely but usually require closer supervision and greater reporting requirements than reg- ular probation. Contacts can range from more than five per week to fewer than four per month. Conditions usually include having a job or attending school, and participating in treatment. Intensive supervision parole has similar requirements and variations for offenders completing their sentences in the community.

Intermediate Supervision Compared to traditional supervision, inter- mediate supervision can include increased drug testing, short jail stays, increased reporting to criminal justice staff, referral to day reporting centers, attending 12-Step meetings, community service requirement, curfews, work release centers, electronic monitoring, and more frequent home visits.

Treatment Levels and Treatment Components Chapter 3, Triage and Placement in Treatment Services, provides detailed infor- mation on selecting an appropriate treatment level. This section builds on the material in chapter 3 to provide information specific to offenders under community supervision. Placement will depend on a number of fac- tors, including the duration and severity of the offender’s substance use as well as the crimes committed. The level of treatment ser- vices recommended for the offender should be individualized and based on a multidimen- sional, diagnostically driven assessment; clini-

214 Chapter 10

cal judgment; and availability of resources in a given community.

Residential Residential treatment for those supervised in the community incorporates several approaches involving cooperative living for people receiving treatment. The most used residential model is the therapeutic communi- ty (TC), which provides a well-controlled, 24-

hour, structured treatment environment. (See chapter 9 for a discussion of prison-based TCs.)

Some programs provide services for 8 or more hours a day, 5–7 days a week, with clin- ical staff available days and evenings. Other residential programs are recovery homes for employed offender-clients, with evening and weekend treatment and limited onsite staff. Facilities may include hospitals or hospital-

215Treatment for Offenders Under Community Supervision

Figure 10-1 Comparison of Probationers and Parolees

Probationers Parolees

Number (as of December 31, 2003) 4,073,987 774,588

Gender (as of December 31, 2003) 77 percent male 23 percent female

87 percent male 13 percent female

Race/Ethnicity (as of December 31, 2003)

African American

Hispanic/Latino (can be of any race)

Caucasian

30 percent

12 percent

56 percent

41 percent

18 percent

40 percent

Crimes 24 percent for drug law violation

17 percent for driving while intoxicated

40 percent for drug offenses

24 percent for violent offenses

Drug or alcohol involved 83 percent (based on State prison- ers expected to be released by the end of 1999)

74 percent (based on State prison- ers expected to be released between 2000 and 2001)

Mental illness 13.8 percent 14.3 percent

Parole/probation violations led to incarceration/reincarceration in 1998

17 percent incarcerated 42 percent reincarcerated

Drug/alcohol treatment as condi- tion of release

41 percent N/A

Mandatory drug testing 32.5 percent N/A

Sources: Beck 2000b; Ditton 1999; Glaze and Palla 2004; Hughes et al. 2001; Mumola 1998; Office of National Drug Control Policy (ONDCP) 2003.

based programs, institutional housing, sec- tions of apartment complexes, and dormitory- like residences.

Most residential treatment programs use a group-centered approach to create an envi- ronment that duplicates certain aspects of a family and makes clients accountable to their peers. Residents collaborate on chores, laun- dry, and meal preparation with the aim of participation in problemsolving, goal setting, and improving cooperation and communica- tion skills. Residential treatment should be followed by continued care in an outpatient setting.

Outpatient Outpatient treatment for probationers and parolees can be provided to many more offenders for the same level of funding as res- idential treatment. It ranges from traditional outpatient services provided by treatment professionals in regularly scheduled sessions in a group or individual setting, to intensive outpatient treatment several hours per week. Because outpatient treatment tends to be more intense in community settings than in correctional institutions, offenders may be receiving more intense treatment than during incarceration. Intensive outpatient treatment includes day or evening programs in which clients engage in a full spectrum of services while living at home or in a special residence. For more details on this level of care, see chapters 3 and 5 of this TIP, as well as the forthcoming revised TIPs, Substance Abuse: Clinical Issues in Intensive Outpatient

Treatment for Alcohol and Other Drug Abuse (Center for Substance Abuse Treatment [CSAT] in development d) and Substance Abuse: Administrative Issues in Intensive Outpatient Treatment (CSAT in develop- ment c).

Within a treatment continuum, intensity decreases over time as the individual meets treatment goals. Offenders may initially be placed in residential settings, followed by intensive outpatient treatment and continuing care. With institution-based treatment as a foundation, outpatient services in the commu- nity can help offenders to continue working on their problems and developing social and work skills in group processes familiar to them from their earlier treatment experience.

Halfway Houses Halfway houses are transitional facilities where clients are involved in schoolwork, work, training, and other activities that do not necessarily include any drug abuse treat- ment when run by the criminal justice system. The halfway house can be a step up to greater liberty (i.e., for a person released from prison) or a step down for an offender in need of greater supervision (i.e., for a person who violated probation requirements). Some clients need halfway houses that can help them stabilize or maintain recovery as they enter society. Usually these programs provide individual counseling along with group, fami- ly, or couples therapy. Offenders can leave the facility for work, school, or therapy but are otherwise restricted to the halfway house,

216 Chapter 10

Dallas County Judicial Treatment Center: A Sample Community-Based Substance Abuse Treatment Program

Dallas County, Texas, established a residential substance abuse treatment program for probationers to relieve prison overcrowding. Based on a modified therapeutic community with a 12-Step component, it included basic substance abuse treatment, life-skills training, drug education, and group counseling. After 1 year, arrests for program graduates were one half of those for probationers who were expelled or transferred. Those who participated in a residential aftercare program had even lower arrest rates (Knight and Hiller 1997).

which is in the community but can be attached to a jail or other correctional insti- tution. House responsibilities are shared and rules must be followed. The length of stay may be related to sentence length and depend on individual progress toward specific goals.

Day Reporting Day reporting centers are facilities to which offenders must report in person or by phone from a job or treatment site as part of their larger supervision plan. The regular report- ing back to probation or parole officers man- dated under this intermediate sanction is aimed at monitoring offender movements or incapacitating them. Reporting must be done at specified times, often throughout the day. Day centers may include assessment for spe- cial needs and such services as anger manage- ment, drug testing, General Equivalency Exam (GED) preparation, drug and medi- cal/mental health treatment, violence preven- tion, community service, and vocational training.

Some day centers primarily function as stag- ing areas from which offenders are sent out in work crews to perform manual labor in the community: cleaning highways, painting schools, etc. Others offer chiefly educational opportunities. In many jurisdictions, day cen- ters have become day treatment centers whose primary mission is to provide outpa- tient alcohol and drug abuse treatment of various intensities. Public or private treat- ment agencies or correctional agency staff may provide the treatment.

Treatment Components Substance abuse is a chronic, relapsing disor- der influenced by numerous interacting biologi- cal, psychological, and social factors. To pro- vide treatment addressing these factors, the consensus panel believes that a full range of services should be available, which might include components from the following list:

• Screening and assessments—medical, psy- chiatric, and substance abuse (see also chapter 2, Screening and Assessment)

• Detoxification (see also the forthcoming TIP Detoxification and Substance Abuse Treatment [CSAT in development a])

• Medical assessment—pregnancy tests and treatment for HIV and AIDS, other sexual- ly transmitted diseases, and tuberculosis (see also chapter 2, Screening and Assessment)

• Full-range medical treatment

• Treatment planning—medical, psychiatric, and substance abuse (see chapter 4, Substance Abuse Treatment Planning)

• Counseling—group, individual, family, cou- ples (see chapter 5, Major Treatment Issues and Approaches)

• Residential treatment for substance abuse

• Substance abuse education—didactic lec- tures, interactive groups, videos, reading assignments, and journal-writing assign- ments

• Relapse prevention services

• Crisis intervention

• Drug testing and monitoring

217Treatment for Offenders Under Community Supervision

Salt Lake City, Utah: A Sample Day Reporting Center

The day reporting center in Salt Lake City, Utah, has been operating since 1994. It serves high-risk/high- need offenders who abuse substances and who have had technical violations or committed new offenses while on probation or parole. Program activities are designed to reduce recidivism and enhance recovery by improving coping skills, preventing relapse, improving job and employment skills, and promoting a smooth reentry to the community. A study of offenders who attended and were discharged from the program during a 1-year period showed that these individuals had fewer property crime offenses, fewer criminal charges, and less substance use in their first year after discharge. A longer stay was associated with better positive outcomes up to 120 days, after which the effect diminished (Bureau of Justice Assistance 2000).

• Self-help education and support

• HIV/AIDS education, testing, and counsel- ing

• Comprehensive pregnancy management— prenatal care and parenting classes and/or childbirth classes

• Mental health services—medications when indicated

• Social and other support services for the offender and family members

• Vocational and educational training

• Family services unrelated to substance abuse treatment

• Assistance in managing entitlements (e.g., food stamps, veterans benefits)

• Acupuncture and other nontraditional adjuncts

• Housing assistance

Additional services may be needed to address sexual abuse, child abuse, domestic violence, victimization, guilt and remorse, and family problems. These can be coordinated on an individual basis through case management and collaboration among system practitioners.

What Treatment Services Can Reasonably Be Provided for People Under Community Supervision? Parolees and probationers receive similar ser- vices in community supervision. This section highlights the panel’s recommended treatment options for both populations.

Basic Needs Parolees and probationers often cannot meet their basic needs. In some situations, treatment cannot begin until such fundamental needs as housing and employment are met. In other

cases, such as when the client cannot maintain prolonged abstinence or when detoxification is needed, the client should be engaged in treat- ment before he or she receives assistance in locating housing or a job.

Housing A lack of housing for offenders under commu- nity corrections supervision is a major prob- lem in most jurisdictions; yet stable living arrangements are crucial to treatment. Available housing often is inconvenient to jobs, public transportation routes, communi- ty social services, or other agencies and includes drug-involved family members and/or friends. Sometimes a halfway house, a “sober house,” or recovery house are better alternatives than the offender-client’s home. Attention to residential resources for clients should be a critical factor in case planning by corrections supervisors. Probation and parole officers should be required to visit and evaluate client residences promptly.

Reintegration With Family Members and Social Support The offender’s home environment often is not helpful for encouraging adherence to treat- ment. Treatment providers should explore the family’s dynamics promptly during a home visit and make alternative living arrange- ments if the environment threatens to under- mine treatment progress. Negative family dynamics take many forms. The offender may be the scapegoat for family problems, making his or her return to the home counterproduc- tive. Also, other family members may be actively using drugs or involved in criminal activities.

Domestic violence and child abuse situations present additional issues, including the per- sonal safety of family members. To determine how healthy the home is, counselors need to make frequent home visits. Generally, com- munity corrections supervisors assess levels of safety in the home when there is a question,

218 Chapter 10

although there are some substance abuse treatment programs that also perform this function.

To supplement the support an offender may be receiving from family members, the treat- ment plan should include recreational oppor- tunities and other outlets to build healthy social relationships.

Vocational Training and Employment Although highly important to an offender’s recovery, vocational training and employment can create problems when they are mandated by the community supervision agency before the offender has been engaged in treatment. If the client has not undergone treatment, there is a high risk that money earned will be spent on drugs or alcohol. Another common result of mandating employment before treat- ment is that the offender may lose his or her job because of behavior related to substance abuse. Achieving and maintaining abstinence depends on structured, phased programming. Vocational training should occur before employment to enable the offender to retain a job or obtain a better one. Wexler (2001a) suggests beginning vocational training at the start of treatment rather than introducing it at the end. Integrating vocational assessment, counseling, training, placement, and followup throughout treatment is a challenge and requires consistent collaboration within and outside of agencies. However, actuating voca- tional treatment goals can serve as the matrix holding all other goals of reintegration into the community. For additional information about vocational issues and offenders, see chapter 8 in TIP 38, Integrating Substance Abuse Treatment and Vocational Services (CSAT 2000c).

Case Management Case management is the process of linking the offender with appropriate resources, tracking his or her progress through required pro-

grams, reporting this information to supervis- ing authorities, and monitoring court-imposed conditions when requested. It should provide the following functions for offender-clients:

• Assessment of the client’s strengths, weak- nesses, needs, and ability to remain crime- and drug-free

• Planning for treatment services and fulfill- ment of criminal justice obligations, such as restitution, community service, or regular contacts with probation officers or other criminal justice officials

• Brokering treatment and other services and ensuring continuity as the client moves along criminal justice and treatment continuums

• Monitoring and reporting progress

• Providing client support, such as identifying prob- lems and advocat- ing with legal, social service, and medical systems in response to needs

• Monitoring urinaly- sis, breath analy- sis, or other chemi- cal testing for sub- stance use

Case management tests the ability of the criminal justice and treatment sys- tems to work collaboratively and is based on two types of agreement: the agreement between the client and the two systems laying out protocols and consequences of infrac- tions, and the agreement between the two agencies, a memorandum of understanding (MOU) that defines how each will manage the caseload of offender-clients in the jurisdic- tion. There can be one or two case managers representing each system. If two case man- agers are involved, they must coordinate efforts, working to encourage a multidisci- plinary response that takes advantage of a

219Treatment for Offenders Under Community Supervision

Attention to

residential

resources for clients

should be a critical

factor in case plan-

ning by

corrections

supervisors.

wide range of treatment and rehabilitation options. For more on MOUs see chapter 11, Key Issues Related to Program Development. For more on case management see TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT 1998a).

Relapse Prevention When an offender experiences relapse, it is crucial to gauge the seriousness of the “slip” to determine appropriate interventions. One positive urine test or one drink after a long abstinence should not be viewed as failure but as a signal for stepped-up treatment and clos- er monitoring. Because resumption of drug abuse can lead to resumption of criminal activity, graduated sanctions for relapses should be specified in the treatment plan. It is essential that personnel from both the crimi- nal justice and treatment systems agree to the range of responses and times when certain responses are appropriate. Repeated relapses must trigger consequences based on danger to the community and the offender’s treatment progress.

The rate of relapse is high among offenders, and relapse prevention training must be pro- vided at the beginning of and throughout treatment, and stressed prior to release. Personal relapse plans should be developed for all parolees receiving treatment. Relapse prevention skills should be part of each offender-client’s treatment plan, addressing how clients can refuse drugs and identify and manage triggers for craving. When relapse occurs, clients must be helped to understand it is part of the recovery process, rather than a personal failure, so they can rededicate themselves to success. If properly handled, relapse can lead to increased motivation for recovery, strengthening an individual’s knowledge of his or her limitations, the dan- gers of stressors, and awareness of what could be lost by leaving the treatment process.

In negotiating the MOUs, treatment and crim- inal justice officials need to collaborate and must support sanctions consistent with treat-

ment so that relapse is not simply punished as a criminal offense. Criminal justice decision- makers at all levels, including judges and court personnel, should be aware that relapse is a characteristic feature of substance use disorder that must be anticipated, prevented, and addressed. Sanction possibilities include

• House arrest

• Assignment to halfway house

• More frequent drug testing

• Electronic monitoring

• Day treatment

• Brief jail stays

• Assignment of community service hours

Treatment Issues for People Under Community Supervision The point at which an individual acknowl- edges the need for drug treatment varies by personal circumstance. What is a crisis for one person is not a crisis for another. However, at a number of junctures many offenders indicate readiness to accept sub- stance abuse treatment. These include the point of arrest, the point of release back to the community, any point at which there is a diversion decision, sentencing, after certain periods of incarceration, on entering proba- tion, or when there is a choice between enter- ing a residential treatment program or a jail. Other critical choice points include changes in one’s social position in the community or per- sonal crises such as the death of a loved one, loss of a job, or suicide attempt.

Because of the diversity of offenders under community supervision, treatment issues vary widely. A parolee recently released after a 20- year sentence will, for example, have differ- ent issues and needs than a probationer who has spent minimal time in a correctional facil- ity and who has more immediate ties to the community. Still, there are treatment issues

220 Chapter 10

that are common to both parolees and probationers. This section addresses those issues. Treatment issues unique to pro- bationers and parolees are addressed in separate sections.

Self-Esteem and Identity Shame and stigma are tremen- dous obstacles for offenders to overcome after an arrest or in making the transition between incarceration and the communi- ty. One effective approach to overcoming this stigma involves encouraging offender-clients to become active as volunteers in support of a community activity. Providing an opportunity for individuals to make a positive contribution to the community— to “give back”—may reduce feelings of alienation and build self-regard.

Stories abound of ex-offenders who experienced a successful recovery from substance use dis- orders through inspirational interventions and became men- tors to young people, playing key roles in steering them toward law-abiding lives. Successful programs recognize the importance of building the client’s sense of worthiness. Program success also depends on the quality of the staff, the treatment approach, and individual client motivation. Given the criti- cal importance of self-esteem to recovery, the panel recommends that training in developing client self-esteem be mandatory for communi- ty corrections personnel.

At the same time, self-esteem is not always a useful treatment target or goal with offenders. Feelings of shame and stigma are sometimes missing, especially in those having antisocial

traits and psychopathy. Targeting self-esteem without also increasing sense of personal responsibility and empathy for others may only result in a more confident criminal. Community service serves to reconnect the offender with the community and allows for retribution.

Financial Concerns Many offenders have multiple financial responsibilities—child support, family obliga-

221Treatment for Offenders Under Community Supervision

Advice to the Counselor: Recommended Treatment Services for People Under Community Supervision

• Help the client address basic needs, such as housing or employment.

• A client’s living arrangements are crucial to treatment. Counselors should be aware of residential resources and collaborate with corrections supervisors and probation and parole officers on finding appropriate housing for clients if needed.

• A client’s treatment plan should include recreational opportunities and other outlets to help them build healthy social relationships in addition to the support clients may be receiving from their family.

• Try to start vocational training for clients at the begin- ning of substance abuse treatment rather than at the end of treatment.

• Case management is an opportunity for the criminal jus- tice and substance abuse treatment systems to collabo- rate to take advantage of a wide range of treatment and rehabilitation options for clients.

• Relapse prevention skills should be part of each offender treatment plan, and personal relapse prevention plans should be developed for all parolees receiving treat- ment. These plans address how clients can refuse drugs, identify triggers, and manage cravings.

• One positive urine test or one drink after a long absti- nence should not be viewed as a failure but as a signal for stepped-up treatment and closer monitoring.

• Graduated sanctions for relapses should be specified in the treatment plan because resumption of drug abuse can lead to resumption of criminal activity.

tions, job requirements, restitution, and treatment schedule—which can be major obstacles to successful treatment. A client burdened with overwhelming responsibilities sometimes gives up, saying, “I just couldn’t handle it.” Criminal justice and treatment professionals need to plan realistic require-

ments for individu- als under communi- ty supervision.

Some communities have recognized the obstacles and stress presented by com- peting assignments and schedules imposed on offend- ers, which often necessitate expen- sive and time-con- suming travel between sites. On Maryland’s Eastern Shore, Tyson’s Food, a major chicken producer,

has given parole officers an office on-site at the processing plant so that employees do not need to miss work to meet reporting require- ments. Drug courts impose numerous report- ing responsibilities, but officials can make a reasonable attempt to accommodate the logis- tics of offenders’ job, treatment, and family responsibilities.

Barriers to Treatment Probationers and parolees may live in fear of the system; their freedom is conditional, and a mistake is likely to lead to reincarceration. Among the many internal barriers that can inhibit treatment success for offender-clients are

• A history of failure

• Alienation from and cynicism about the social structures and governmental agencies that typically have had a major impact on them

• A sense of hopelessness that anything can make a difference in their lives

• A culturally supported belief that treatment is for weak people

• The perception that treatment is further punishment

Those working with probationers and parolees need training to address each of these barriers. It is important for profession- als working with offenders under community supervision to learn that offenders often do not realize that the goal of community correc- tions is to prevent them from being reincar- cerated. Another treatment component should address the realities of incarceration and the impact of being a felon. Offenders being supervised in the community need to be informed of what they stand to lose by violat- ing supervision requirements.

Motivation for Treatment Establishing an offender’s motivation to change is an essential first step in substance abuse treatment. It cannot be skipped. Generally, clients lack focus or goals, which must be established to permit motivation. Those working with probationers and parolees need to be familiar with techniques of motivation and how to create and/or sup- port the offender’s desire to break a pattern of criminality. Without genuine motivation on the part of the offender-client, treatment problems can be guaranteed. Clients need to feel hope and counselors need to plan a con- tinuum of events that can begin to generate hope. During early stages of treatment, the offender-client should be oriented toward small accomplishments.

Flexibility on the part of community correc- tions officials is important. Both treatment programs and corrections agencies can work together to build opportunities for success— keeping an appointment, having a clean urine test, or completing homework—small, struc- tured steps that clients can take with relative ease and derive confidence from as they

222 Chapter 10

Establishing an

offender’s

motivation to

change is an

essential first step

in substance abuse

treatment.

progress. When the client completes one goal, the provider should be ready to suggest the next. Incentives can be built into the system as well. For example, the more frequent the negative drug test results, the less frequent the mandatory testing.

Those who abuse substances often are gifted manipulators with long histories of manipula- tive behavior in many systems. They may be able to simulate motivation but lack any real emotional investment in changing behavior. Clear, consistent, and uniform messages pro- mote recovery and prevent the two systems from being used against one another. If the word “on the street” is that staff can be manipulated, treatment providers will face an uphill battle with many clients.

Motivational interviewing is one of the most frequently used strategies for enhancing moti- vation. The technique assumes the client’s ambivalence about change and produces cog- nitive dissonance by eliciting the negative con- sequences of the addictive behavior. Motivational interviewing has been effective in the treatment of alcoholism (Bien et al. 1993; Galbraith 1989; Miller and Rollnick 1991) and methadone treatment for opioid abuse (Saunders et al. 1995; Van Bilsen and Van Emst 1986). For more on motivational interviewing, see the section on brief treat- ment in chapter 8 and TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b).

Negative Counselor Attitudes Treatment is impeded when counselors have a negative perception of the client’s desire to change, believe there is a poor prognosis for recovery, or are reluctant to serve offenders in general. Clients easily pick up on a provider’s negative attitude, which often con- firms their own feelings about the futility of attempts to give up drugs. The cross-training of professionals helps build an understanding of offender-clients’ needs and potential, but professionals in both systems must acknowl- edge that the very nature of substance abuse

means that maintaining recovery is a long- term goal.

Lifestyle Changes The kinds of changes community corrections professionals ask drug offenders to undertake are extraordinarily challenging and difficult to contemplate on a personal level. Many offenders have had limited experience with success and few opportunities to test their ability to succeed. A drug court or prison may be the first setting in which some offend- ers have a genuine chance to discover the capacity to change their lifestyles.

A counselor who is a role model of courage or compassion can often be very effective in per- suading clients to reevaluate their lifestyles. On the other hand, counselors should also be prepared for setbacks, lapses, and slow progress, as offenders come to terms with the extent of lifestyle change that is being asked of them.

Self-Help Groups Self-help groups frequently are a crucial com- ponent in recovery; they can provide peer support and nurture positive change. As bridges between incarceration and communi- ty, they can help with crises and personal growth. Probation and parole officers often advise clients to attend well-known programs like Alcoholics Anonymous or Narcotics Anonymous, saying, “Don’t take my word. I’m not the expert. Listen to the folks who’ve been there.” Other self-help groups may be appropriate depending on a client’s beliefs, needs, and interests, such as Survivors of Incest Anonymous, Secular Organizations for Sobriety, church or feminist groups, or veter- an organizations. Practitioners need to remember, however, that although self-help groups are not a substitute for counseling, they can be an important adjunct to it.

223Treatment for Offenders Under Community Supervision

Adherence to Supervision Conditions Both parole and probation officers need to be attuned to treatment needs, the dynamics of substance use disorders, and the changes required to maximize an offender-client’s chance to succeed. Training needs to be pro- vided to them on how to craft requirements that support a client’s potential for success. Flexibility must be built into the require- ments, given the complex pressures on most offenders in the community. Cross-training is necessary to facilitate information sharing among the entire range of professionals involved from presentence to probation or parole. While public safety is always a priori- ty, training for probation and parole officers should emphasize that the offender’s long- term treatment will bring sustained improve- ments in public safety.

Revocations because of technical violations of probation or parole requirements are a major barrier to completion of successful treatment. Required expectations for offender behavior need to be realistic. Cross-training can be helpful in fostering a shared vision of success. Such training should have specific goals. For example, the consensus panel suggests that training for probation officers working with drug offenders could include education on what treatment is and is not. Generic models of treatment should be presented. Similarly, treatment professionals working with drug offenders should be trained on the role of parole and probation in the criminal justice system. Probation and parole are frequently the most misunderstood element of the sys- tem, considered to be “law enforcement” by treatment professionals and “social work” by law enforcement. Often the breakdowns in communication between probation, parole, and treatment professionals are the result of a lack of understanding of each other’s roles.

Vulnerability to Relapse Both parole and probation officers, who may have a supportive role before the client enters treatment, are likely to move into supervisory mode once treatment is underway to reduce public safety and liability risks. Zero toler- ance and “three strikes” policies make it diffi- cult for officers to overlook drug lapses and contradict knowledge that substance use dis- order is a chronic disease. Relapse is not nec- essarily a failure. The common belief that treatment does not work is often based on the fact that most people recovering from sub- stance use disorders relapse from time to time.

Roles as Workers and Taxpayers Not only have arrests and imprisonment removed many young men and increasing numbers of young women from their commu- nities and families, the majority have no financial resources to cushion their return. Their length of time away from the job world and lack of skills or experience to enter the marketplace leave many offenders low on the job ladder and further unable to support families or meet social expectations. Simply having a job, and particularly paying taxes, can be a completely foreign experience for many offenders. If parole or probation reporting and other multiple requirements are inflexible, they can prevent clients from being able to earn a living and contribute as tax-paying citizens.

Increasingly, vocational training, GED pro- grams, and job readiness training are being added to treatment. If programs do not offer these services, they can link to community agencies that can provide them. Offenders need specific preparation for responding to a prospective employer’s questions about their past. Lying is often a first choice, given the prospect that admitting to a criminal history will likely bar them from the job. A felon may

224 Chapter 10

be legally obligated to disclose a criminal past.

Treatment for Specific Populations Both probationers and parolees with substance use disorders are likely to have additional treat- ment needs. Model programs described at the end of this chap- ter include comprehensive ser- vices to address a range of issues. This section briefly highlights the treatment issues of specific popu- lations. For more detailed infor- mation, see chapter 5, Major Treatment Issues and Approaches.

People with co-occurring disorders Of the 74 percent of probation- ers and parolees identified as having drug and/or alcohol problems, 11.4 percent were also identified as having mental illness (Beck 2000c). The preva- lence of co-occurring disorders among these populations means that many offenders will need assistance with their mental ill- ness as well as their drug or alcohol problems. Treatment for co-occurring mental disorders should be tailored to the partic- ular treatment plan, and revised according to ongoing assessment. Coordinated (integrated when possible) ser- vices are especially important for offenders with mental illness. An example of one model for treating offenders with mental illness is highlighted on the next page.

The National GAINS Center for People with Co-occurring Disorders in the Justice System

provides an online information source of value to those who work with offenders. The GAINS Center collects and analyzes informa- tion, and develops materials specifically for people who work with offenders with mental illness, and provides technical assistance to help localities plan, implement, and operate appropriate, cost-effective programs. For further information go to www.gainscenter.samhsa.gov/.

225Treatment for Offenders Under Community Supervision

Advice to the Counselor: Treatment Issues for People Under

Community Supervision • Counselors can help offenders overcome the stigma of

past incarceration by encouraging them to become active as volunteers in support of a community activity.

• For some clients financial stresses can be an obstacle to successful treatment. Counselors can work with criminal justice personnel to help plan realistic financial require- ments for clients.

• Counselors need to help clients address any internal bar- riers clients may be experiencing, such as a history of fail- ure, sense of hopelessness, or the perception that treat- ment is further punishment. Counselors can help offend- ers understand that the goal of community corrections is to prevent them from being reincarcerated.

• An essential first step for treatment is to establish a client’s motivation to change. Counselors should be familiar with motivational techniques (such as motiva- tional interviewing) and how to create or enhance a client’s desire to break a pattern of criminality.

• Counselors should be careful not to project negative atti- tudes, which might be picked up by clients and reinforce their feelings of futility about substance abuse treat- ment.

• Being a role model of courage or compassion can be effective in persuading clients to reevaluate their lifestyles and make positive changes.

• Self-help groups can be a crucial component in a client’s recovery by providing peer support and nurturing posi- tive feelings.

• Counselors can help clients applying for employment prepare for responding to a prospective employer’s ques- tions about their past.

Female clients and children Nearly a million women were on probation in 2003, and nearly 100,000 were on parole (Glaze and Palla 2004). Women under com- munity supervision accounted for 85 percent of females in the criminal justice system in 1998. About 45 percent of women whose parole ended in 1996 were back in prison or had absconded. Women who successfully fin- ished parole were incarcerated for an average of 15 months and on parole for an additional 20 months (Greenfeld and Snell 1999).

Mothers who are to be incarcerated often lose custody of their children because of neglect and/or abuse, but the loss of children is extremely difficult for them to accept. If chil- dren are removed, criminal justice and treat- ment providers need to consider providing assistance for dealing with grief and loss. A client who has demonstrated a sustained peri- od of sobriety during treatment should be considered for a phased return of her chil- dren. Mothers reentering the community from correctional institutions are likely to have a difficult time reuniting with their children. They and their children should work with family service agencies on reunification issues, when appropriate.

Clients with HIV/AIDS or other illnesses Offenders face additional challenges when they are unable to work because of illness. Access to medical help is essential. The con- sensus panel believes that comprehensive assistance to offenders should include preven- tion education, medical and social service support, grief counseling, and other psycho- logical services. Services should include infec- tious disease risk assessment and screening, medical interventions such as primary care, and family counseling. Continuing care should include followup and hospice care. Case managers can assist in coordinating care for such infectious diseases as HIV, hepatitis C, tuberculosis, and sexually transmitted dis- eases. For more on infectious diseases in criminal justice clients, see chapters 2 and 6.

Treatment Issues Specific to People on Parole Prisoners released into the community face a sometimes bewildering transition. Nearly 80 percent of prisoners returning to the commu-

226 Chapter 10

PACT (Programs for Assertive Community Treatment)

The PACT model targets individuals with severe and persistent mental illness (which may include schizophrenia and other psychotic disorders, bipolar disorder and severe and recurrent depressive dis- orders, and occasionally severe personality disorders or severe anxiety disorders). Many if not most PACT clients have co-occurring addictive disorders, medical problems, and more than one psychiatric illness. The hallmark of PACT is low caseload size (15 clients per staff person) and an integrated team approach that includes people with medical, psychiatric, nursing, social work, psychology, case manage- ment, addictions, and other expertise who view the clients as a shared responsibility. Typically these programs will follow the client across locations. They do outreach into homeless shelters and street loca- tions, they work with other providers when the client is hospitalized, and they will work with jails to advocate for good treatment.

Research indicates that PACT is effective in reducing hospital recidivism and, less consistently, in improving other client outcomes (Drake et al. 1998a; Wingerson and Ries 1999). Another study com- pared a PACT with a standard case management approach at 3-year followup. The results indicated that the PACT adapted for clients with co-occurring disorders produced greater improvements on mea- sures of quality of life and clinician ratings of alcohol use and substance abuse (McHugo et al. 1999).

nity are released on parole under conditional release (Petersilia 2000). A successful transi- tion from offender to citizen often depends on successful treatment. Successful treatment helps individuals to be more realistic about their strengths and weaknesses, more skilled and willing to endure obstacles encountered in maintaining a job or obtaining an educa- tion, and more confident about meeting fami- ly and work responsibilities.

Continuum of Care Because substance use disorders are long- term, relapsing illnesses, a crucial aspect for reentry is to develop and sustain an integrat- ed continuum of care between substance abuse treatment providers, the parole officer, and social service agencies that can assist the inmate’s reintegration into the community. Ideally, cross-system integration for offender transitional services contributes to cost bene- fits as a result of reduced recidivism (Inciardi 1996; National Institute of Justice 1995; Swartz et al. 1996). However, the parolee does not exist in a discrete, well-coordinated system, but rather in a cluster of independent agencies and entities with separate justice responsibilities. Some entities collaborate closely; others do not. Most operate under separate funding streams, with differing orga- nizational missions that may or may not share philosophical orientations toward public safe- ty and offender rehabilitation. Boundary spanners and case managers can sometimes help maintain continuity. TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community (CSAT 1998b), discusses this topic in depth.

Aftercare and Continuing Care Several studies have supported the long-term efficacy of postprison aftercare and treatment services in the reduction of recidivism and relapse. For example, Wexler (1995) found that those who participated in prison- and community-based therapeutic community treatment committed fewer crimes than their

counterparts who did not receive aftercare services. Inciardi (1996) reported similar findings: lower rates of drug use and recidi- vism than those enrolled only in institutional treatment programs.

Residential aftercare contributes to improved postprison outcomes. For optimal results, the offender should remain in treatment in the community. Studies show, for example, that the most effective treatment lasts a minimum of 3–6 months, and outcomes improve with additional time in treatment. This is true for all treatment modalities and particularly for treatment of offenders (Hubbard et al. 1988; Simpson 1984; Wexler 1988).

Case Management Case management is the crucial function that links the offender with appropriate resources, tracks progress, reports information to super- visors, and monitors conditions imposed by the supervising agency. These activities take place within the context of an ongoing rela- tionship with the client. The goal of case man- agement is continuity of treatment, which, for the offender in transition, can be defined as the ongoing assessment and identification of needs and the provision of treatment without gaps in services or supervision. Account- ability is an important element of a transition plan, and case management includes coordi- nating the use of sanctions and incentives among the criminal justice, substance abuse treatment, and possibly other systems.

Ideally, case management activities should begin in the institution before release and continue without interruption throughout the transition period and into the community. Reassessments should be conducted at vari- ous stages throughout the incarceration and community release process. These periodic assessments should form the basis for ongoing case management and service delivery.

Ancillary services are needed before and after release to prepare the offender for the return to family, employment, and the community.

227Treatment for Offenders Under Community Supervision

Studies (Knight et al. 1999a; Martin et al. 1999; Wexler et al. 1999b) have revealed the importance of aftercare for the maintenance of treatment effects. Foremost among needs for ancillary services are drug-free housing or other living arrangements, employment, fami- ly support, transportation, education, and primary health care. Others include literacy training, HIV/AIDS education, and prosocial support networks (Belenko and Peugh 1998; Hiller et al. 1999b). Offenders may need help learning basic life skills such as budgeting, using public transportation, and parenting. Improving clients’ likelihood of obtaining a job through GED preparation, enrollment in an educational program, vocational training, or job-seeking skills classes increases their chances of success after release.

This array of services reflects the multiple psychosocial needs of offenders and takes into account the likelihood that they may experi- ence periods of relapse, requiring more inten- sive levels of treatment and supervision. Other needs are training to improve interper- sonal skills within families and among peers and training in anger management to learn

new methods for resolving conflicts. Family members should be involved whenever possi- ble, and participation in self-help groups should be encouraged.

Recidivism Parole failures now account for 35 percent of all prison admissions. Two-thirds of all parolees are rearrested within 3 years (Petersilia 2000), many on technical revoca- tions, but most rearrests occur in the first 6 months. Offenders with mental illness are espe- cially likely to be rearrested.

Given the importance of aftercare in the reduction of recidivism, several Federal and State Initiatives have sought to provide inte- grative treatment. One such program, the Serious and Violent Offender Reentry Initiative, is highlighted below.

228 Chapter 10

Serious and Violent Offender Reentry Initiative

In conjunction with several Federal partners, the U.S. Department of Justice, Office of Justice Programs, created a comprehensive program to reduce violent crime by helping high-risk offenders pre- pare for reentry to society. The Initiative provides funding for the development, implementation, and enhancement of reentry programs. Programs funded under the Initiative will be tailored to address the three phases of reentry:

• Phase 1—Protect and Prepare. Institution-based programs will provide services to prepare the offender for reentry, including education, mental health and substance abuse treatment, job training mentoring, and diagnostic and risk assessment.

• Phase 2—Control and Restore. These community-based transition programs will assist offenders prior to and immediately following their release by providing education, monitoring, mentoring, life skills training, assessment, job skills development, and mental health and substance abuse treatment.

• Phase 3—Sustain and Support. In this phase, community-based, long-term support programs help offenders who have successfully completed their criminal justice supervision to connect with social ser- vices agencies and community-based organizations that provide ongoing services.

Further information on the Serious and Violent Offender Reentry Initiative is available at the Office of Justice Programs Web site: www.ojp.usdoj.gov/reentry/learn.html.

Treatment Issues Specific to Probationers Compared to parolees, proba- tioners are less likely to have spent extended time in a correc- tional facility, and their ties to the community are relatively intact. The latter is both a ben- efit and a detriment in terms of substance abuse. On the one hand, offenders on probation may have the support of their families and their communities. They may be able to maintain some consisten- cy in their employment, their residence, and their family lives. On the other hand, proba- tioners face a more immediate return to the surroundings and influences associated with their drug or alcohol use. For example, the offender with alcohol dependence is likely to return to the same neighborhood with the same bars, liquor stores, and friends.

As with parolees, in order to be effective treatment must necessarily focus on changing ingrained patterns of behavior and thinking and avoiding the people, places, and things that the offender associates with drug or alco- hol use. Unlike people on parole, however, the issue is not so much to reintegrate into society, but rather to learn new ways to live in that society. Much of the information pre- sented in chapter 7 is also applicable to pro- bationers, since many probationers have been sentenced through drug courts.

Strategies for Improving System Collaboration Initiatives such as cross-training, coordinated and comprehensive planning, and followup interdisciplinary meetings can help justice and treatment system partners to develop a shared, client-centered mission and a coordi-

nated response. Figure 10-2 (next page) pro- vides an example of how the goals of the treatment and criminal justice systems can be viewed as similar, although on the surface they appear disparate.

Memorandum of Understanding When a substance abuse treatment program and a criminal justice agency collaborate, an MOU will outline the objectives of each part- ner, the expectations each partner has about the obligations of the other, and communica- tions between the program and the criminal justice agency. For programs treating offend- ers, it is crucial to identify who will make cer- tain decisions and what kinds of information will be reported. For example, will the pro- gram or the criminal justice agency decide when an offender’s relapse into alcohol or drug use will be handled as a violation of the conditions of probation? How detailed are the program’s reports to the criminal justice agency? Matters such as these can be resolved upfront between the program and criminal justice agency. An MOU or letter of agree- ment makes explicit the responsibilities agreed upon by each system.

229Treatment for Offenders Under Community Supervision

Advice to the Counselor: Treatment Issues for People on Parole

• Counselors can collaborate with parole officers and social service agencies to assist a client’s reintegration into the community and help maintain the continuity of services.

• Counselors can help clients with securing postprison aftercare and treatment services, which have been shown to reduce recidivism and relapse.

• Ancillary services (e.g., drug-free housing, employment, family support, transportation, education, health care) are needed before and after release from prison to pre- pare the client for return to the community.

Information-Sharing and Confidentiality Issues To develop effective treatment plans that respond to individual needs and problems, community-based organizations need infor- mation from the paroling institution about the offender’s previous substance abuse treat- ment. Obtaining such information often is problematic because of ethical considerations about client privacy and Federal laws guaran- teeing strict confidentiality of information about all people receiving substance abuse prevention, assessment, and treatment ser- vices. For more detailed information on confi- dentiality and privacy, see chapter 7. (Additional information on confidentiality can be found at www.hipaa.samhsa.gov; also consult CSAT 2004.)

Program Violations Ideally, program violations should be addressed in the context of treatment needs before legal sanctions are considered, depending on the severity of the violation. However, this is realistic only if the supervis- ing agent and the provider of care agree on how to make it work; it is not realistic if there is not a solid agreement between the two sys- tems. When possible, this understanding can

be established by an initial agreement between the offender-client’s probation or parole officer and treatment provider.

Personnel and Training While some States do not require licensing for treatment providers, it is undesirable to have unaccredited, unlicensed people providing treatment. The consensus panel feels strongly that individuals providing treatment to offender populations should meet minimum standards of recognized accrediting authori- ties in addition to receiving specialized train- ing in substance use disorders and relapse prevention. Special attention needs to be paid to the training of recovering staff who are essential counseling resources for therapeutic communities and other programming. Their credibility with clients and role modeling potential cannot be underestimated. Programs that include opportunities for clients to begin counselor training while in custody enrich programs and offer increased hope for participants. However, careful guidelines are needed concerning crime-free and sober years, in addition to other stan- dard professional counselor requirements.

Whenever possible, training should be car- ried out across criminal justice and substance

230 Chapter 10

Figure 10-2 Paradigm of Collaboration

GGooaallss ooff TTrreeaattmmeenntt SSyysstteemm GGooaallss ooff SSuuppeerrvviissiioonn SSyysstteemm SShhaarreedd GGooaallss

• Reduce recidivism/criminal behavior.

• Provide evaluation and treat- ment services.

• Practice social skills.

• Develop working alliance.

• Prevent secondary pathology.

• Collaborate/consult with other providers.

• Honor confidentiality.

• Reduce recidivism/criminal behavior.

• Maximize the use of databases on the offender.

• Enhance supervision.

• Rely on third party expertise.

• Focus on public safety.

• Respond to court mandates.

• Minimize risk to public.

• Obtain adherence to treatment plan and abstinence from sub- stance use.

• Alleviate symptoms of illness.

• Promote successful community reintegration with the goal of abstinence.

• Encourage family/social support.

• Support employment efforts.

abuse treatment systems and should integrate personnel from both. The curriculum should cover needs and approaches to specific popu- lations in the jurisdiction, such as women, minorities, those with co-occurring mental disorders, and clients with special needs, and incorporate input from each of these groups to ensure the training’s relevance, accuracy, and sensitivity. General topics to consider include

• A broad overview of how each system works

• Common ground shared by substance abuse treatment and criminal justice systems

• Education on the language and jargon of the systems so that providers understand each other’s language

• Clarification of system roles and personnel roles within each system

• Ways in which the two systems can communi- cate, work together, and manage conflicts

• Cultural competence issues

• Confidentiality requirements

• Effective case management for the offender- client

• Rationales for intermediate sanctions pro- grams for drug offenders

• Eligibility requirements for intermediate sanctions programs and how they can be applied to individual cases

• Reporting requirements and agreements

• Pharmacotherapy

Participants in training for this type of commu- nity supervision program should include

• Judges

• Prosecutors

• Probation and parole officers

• Treatment program administrators

• Counselors

• Public treatment-funding agencies

• Defense attorneys

• Ancillary program staff

Special presentations can be made to policy- makers (e.g., State and local legislators or advi- sors to the State or county) that focus more on systems and legislative issues. For more on training on screening and assessment, see chap- ter 2. For general information on treating offenders, see chapter 5.

Sample Programs

Treatment Accountability for Safer Communities For a description of TASC, see chapter 7.

The Amity Project The Amity Project was a collaboration between Amity, Inc., and the Pima County, Arizona, Department of Probation and fund- ed by The Center for Substance Abuse Treatment, U.S. Department of Health and Human Services, in 1990. The program tar- geted offenders who were at high risk of hav- ing their probation revoked because of their substance abuse. By incorporating the key elements of a therapeutic community into a day and evening program, the unique struc- ture escalated sanctions, including urine screens and varying supervision levels, case management, educational and vocational training, family support and counseling, coor- dination of medical services, and intensive aftercare. After 2 years, drug use relapses among probationers declined, positive urine screens decreased by more than 50 percent in the first year, and job placement increased. Because of the success of the employment component, the project had to extend its activities to nights and weekends to accommo- date the employed offenders. The program ended when funding was not renewed, despite its promising start (Healey 1999).

231Treatment for Offenders Under Community Supervision

Breaking the Cycle A joint project of the ONDCP and the National Institute of Justice, U.S. Department of Justice, Breaking the Cycle is designed to interrupt the downward spiral of drug use, crime, imprisonment, and recidi- vism and is currently being tested by three adult justice systems nationwide. The goal of the program is to reduce drug use and crime through increased collaboration between jus- tice system practitioners and treatment providers. The Breaking the Cycle model encourages a change in the way both systems respond to offenders who use drugs and includes the following initiatives:

• Drug testing of all arrestees before the initial court hearing

• Placement of people who use drugs in appro- priate treatment and monitoring programs

• Intensive pretrial and post-sentence case management

• Appropriate, graduated sanctions and incen- tives to address offender behavior

• Judicial oversight of offender compliance (National Institute of Justice 2001)

Probationers in Recovery An intensive probation program in San Diego County, California, Probationers in Recovery requires offenders to participate in intensive drug treatment and drug testing. The pro- gram has made a strong effort to combine substance abuse treatment with the height- ened surveillance of intensive supervision. The program targets high-risk offenders and excludes people with psychotic disorders and excessive criminal or violent histories. The requirements for program completion are comparatively high, including self-help, group and individual therapy, job club, drug educa- tion, social skills development, and life skills components lasting a minimum of 6 months (Curtis et al. 1994).

KEY–CREST Located in Wilmington, Delaware, KEY- CREST has an in-prison therapeutic commu- nity, and a 6-month residential, community- based TC with a work release program for inmates with histories of substance abuse. The program includes an aftercare stage, where clients are under community supervi- sion. Data from a 3-year followup indicate that the group in aftercare shows the most powerful effects of the earlier treatment (Martin et al. 1999). For additional informa- tion, see chapter 9.

Special Offender Services Program One model program for the treatment of offenders who have developmental disabilities or at least three deficits in essential adaptive skills or behaviors was developed in the mid- 1980s by Lancaster County, Pennsylvania. This program, known as Special Offenders Services (SOS), helps qualified offenders who have been placed on probation or parole. SOS works in a number of areas to help this group by educating criminal justice person- nel, facilitating the use of social services (through case management), building client self-esteem (which it does by rewarding small successes and not placing unreasonable demands on its clients), educating clients about their rights and responsibilities, and providing skills training in areas such as recreational activities (since many offenders who are cognitively challenged may not know how to spend their free time). The program’s success is demonstrated by the extremely low recidivism rate of its clients, which, as of 1992, was only 5 percent (Wood and White 1992).

232 Chapter 10

Conclusions and Recommendations Based on their knowledge and experience, consensus panel members offer the following conclusions and recommendations regarding treatment for probationers and parolees:

• Offenders can be effectively controlled and managed by a combination of treatment and surveillance while on probation at a far lower cost than if they are in jail or prison.

• Offenders under community supervision who have substance use disorders need ser- vices from multiple systems. Services should be accessible on an as-needed basis to ensure positive outcomes and smooth tran- sitions.

• Cross-training of probation and parole offi- cers, case managers, and substance abuse counselors is vital for the delivery of coor- dinated services.

• Community supervision should be based on the recognition that relapses are unavoid- able and not necessarily indicative of fail- ure. Intensification in the level of supervi- sion should be matched by an intensifica- tion of the level of treatment. Likewise, the intensity of supervision should decrease over time as the individual meets treatment goals.

• Probationers who have avoided incarcera- tion should receive education on the reali- ties of incarceration and the impact of being a felon on the offenders’ lives.

• Ideally, case management activities for parolees should begin in the institution before release and continue throughout the transition period for a minimum of 3 months of treatment after release.

• Reassessment should be conducted through- out the period of community supervision.

• All residential treatment should be followed by continued care in an outpatient setting.

• Optimally, probation and parole officers should visit and assess the client’s residence and place of employment periodically in the course of community supervision.

• Vocational programming should be ongoing and integrated with substance abuse treat- ment.

• Community supervision staff should be involved in treatment planning and treat- ment team activities whenever possible, particularly when issues of sanctions and placement in community treatment are reviewed.

233Treatment for Offenders Under Community Supervision

235

11 Key Issues Related To Program Development

Overview An important thread running throughout this TIP is the interdepen- dence of criminal justice and substance abuse treatment systems, which influences what program activities are undertaken and how they are implemented. The members of the TIP consensus panel feel strongly that effective collaboration between the criminal justice and substance abuse treatment systems can result in better treatment for offenders and, ultimately, a reduction in crime. When available and effectively implemented, substance abuse treatment programs can reduce recidivism, reduce substance use, and help offenders to change their lives. The guiding notion in this chapter is to provide thoughtful consideration of key issues that frame effective programming and coordination.

This chapter is primarily aimed at program administrators, although counselors will benefit from reading it as well. The chapter presents information on issues such as reconciling the goals of the criminal jus- tice and substance abuse treatment systems; the interdependence of the two systems and how to collaborate effectively; program-level coordination, including barriers to coordination and solutions, and integrating criminal justice and substance abuse treatment; research and evaluation issues; cost issues; and conclusions.

Reconciling Public Safety and Public Health Interests Any discussion concerning the effectiveness of substance abuse treat- ment for clients under criminal justice supervision needs to address the historic differences between the criminal justice and public health systems. These differences influence the nature and quality of services provided at both the program and policy levels. A basic difference is the primary focuses of the two fields. The responsibility of the crimi- nal justice system is to protect the public safety, with a focus on activi-

In This Chapter…

Reconciling Public Safety and Public Health

Interests

Interdependence of Criminal Justice and Treatment Systems

Program-Level Coordination

Research and Evaluation

Cost Issues

Key Goals of SAMHSA

Conclusions

ties designed to isolate, and supervise individ- uals who threaten the lives and well-being of others (Office of the Federal Register 2004). The substance abuse treatment system’s focus is on restoring individuals to productive lives and minimizing the consequences of alcohol and drug dependence on people with sub- stance use disorders, their families, and com- munities.

Because of these differences in focus, the two systems sometimes operate at cross-purposes. The perceived need to “get tough” on crime and the rehabilitation of the offender have

fueled the contin- ued debate. Offenders are sometimes viewed as less deserving competitors for scarce substance abuse treatment services compared to nonoffending cit- izens. For some, punishment is the primary goal; treat- ment—if available at all—is sec- ondary.

At the same time, security and public safety issues may not be a primary consideration for substance abuse treatment professionals. Counselors may for- get that offenders are there because they have committed crimes, sometimes violent ones, and that not all offenders will become law- abiding citizens, even if they are not under the influence of drugs or alcohol. Moreover, some treatment programs may not address the additional needs of criminal justice clients, such as issues underlying criminal activity (e.g., criminal belief systems and criminal peer groups).

Despite these differences, the missions of pub- lic health departments and correctional agen- cies are complementary. An important com- mon ground—a goal that is critically impor-

tant to both systems—is the reduction of crime. The remainder of this chapter addresses ways to build on that common ground to create systems that habilitate offenders, prevent crime, and protect the public.

“Good treatment is good public safety.”

—Claire McKaskill, former county prosecutor in Missouri

Interdependence of Criminal Justice and Treatment Systems The criminal justice and substance abuse treatment systems can work together to improve the results of both systems. The Criminal Justice Treatment Planning Chart prepared by the Center for Substance Abuse Treatment (CSAT) might serve as a frame of reference (CSAT 1994b). In the chart (Figure 11-1, pp. 238–239), specific connections between the criminal justice and substance abuse treatment systems are targeted.

It is vitally important that these two systems, and the people who work within them, agree that treatment must be tailored to the partic- ular criminal justice setting and to the client’s stage in the recovery process. Steps to pro- mote integration between the criminal justice and the substance abuse treatment systems are discussed below.

Effective Collaboration Between Criminal Justice and Treatment Systems Several conditions must exist for effective rela- tionships between different groups or systems (Argyris 1970), such as the treatment and crim- inal justice systems. These conditions include

• Investment in the system’s effectiveness

• Confidence in their own system

• Belief in the interdependent nature of the systems

236 Chapter 11

The missions of

public health

departments and

correctional

agencies are

complementary.

• Willingness to accept or develop common goals to link the systems

• Willingness to work collaboratively with other systems on joint projects

The consensus panel recommends the following basic principles, which are used to promote change in different organizations and systems but can be applied to the criminal justice and substance abuse treatment systems:

• Development of leadership and goals

• Endorsement from system leaders

• Establishment of common goals and objec- tives

• Identification of stakeholders

The following section describes how these rec- ommended principles can be used to strengthen coordination between criminal justice and sub- stance abuse treatment systems.

Development of leadership and goals Small groups of individuals who have endorse- ment of leadership within the criminal justice and substance abuse treatment systems can help develop an agenda for action. Preliminary goals that link the two systems can then be established. It is important that preliminary goals identified are specific and attainable. Building on small successes at the beginning of the process is important.

Endorsement from system leaders Formal endorsement should be obtained for collaborative projects from both systems’ leaders. Endorsement may be implicit if lead- ers are part of the group or may be obtained from a more formalized process if they are not. This endorsement can take the form of an executive order from the governor, mayor, or commissioner; a legislative declaration for the group’s work; or simply a memorandum of understanding from those who hold power

in the criminal justice and substance abuse treatment systems. Whoever commissions the collaborative project activities must be kept informed about progress and goals at every stage, preferably in an informal, uncompli- cated way. A systems audit may be an effec- tive way to measure the starting point and level of collaboration. This may be conducted internally by project staff or by external eval- uators.

Establishment of common goals and objectives For systems collaboration to be effective, a unifying goal must be identified and pursued. The planning group should set a unifying goal that encompasses the needs of both the sub- stance abuse treatment and criminal justice systems. For example, a goal to reallocate money from current treatment programs in order to treat other groups of offenders may be divisive rather than unifying. However, a goal of finding new funding for offender treat- ment that focuses on the most dangerous offenders is an example of a superordinate or unifying goal. The process of articulating goals will help to clarify and resolve differ- ences among group members and to expedite project development. As soon as the goals have been determined, objectives should be described. A series of concrete objectives should be accompanied by an action plan to achieve the goals. The objectives should then be assigned to individual group members for followup.

Identification of stakeholders Everyone has a vested interest in preventing and addressing crime related to substance abuse. As the example of Portland’s Regional Drug Initiative (see text box on page 240) demonstrates, when systems and individuals work together the results can be impressive.

237Key Issues Related to Program Development

238 Chapter 11

239Key Issues Related to Program Development

Figure 11-1 CSAT Criminal Justice Treatment Planning Chart

The following groups can be targeted to gar- ner support for initiatives designed to provide substance abuse treatment for offenders.

The public. As taxpayers, voters, and resi- dents, the public can influence what happens at every point along the criminal justice treat- ment continuum. As such, they are primary stakeholders who should be kept informed of

relevant issues. For example, officials might consider releasing an annual community progress report, similar to a corporate annual report that includes facts such as the number of people who have successfully completed a treatment program. When members of the public participate in planning, an ongoing educative process is initiated. Public involve- ment also can address fears associated with

240 Chapter 11

Regional Drug Initiative, Portland, Oregon

In 1987, citizens and leaders in Portland, Oregon, and surrounding communities united to form a coali- tion, the Regional Drug Initiative (RDI). Although the RDI was dissolved in June 2002, it continues to serve as a national model for community coalitions. Join Together hosts an archival Web site (www.regionaldruginitiative.org) that contains basic documents describing RDI, its approach, and how to replicate its work.

RDI’s purpose was to substantially reduce alcohol and drug abuse in Portland and Multnomah County. It worked to coordinate networking efforts of the criminal justice system, treatment and prevention agencies, healthcare and education systems, community organizations and advocates, youth, the faith community, businesses, and the media. RDI aimed to increase the number of drug-free workplaces, strengthen youth and adult leadership to reduce alcohol and drug use among youth, and educate com- munity leaders and the public on actions and policies needed to reduce substance abuse.

The Drug Impact Index was an annual compilation of indicators that highlighted the severity of the drug problem in Oregon and Multnomah County. The last volume of the Index (2001) showed that approxi- mately one fifth of those needing substance abuse treatment in Oregon received it in any one year.

The Index also showed that that when stakeholders cooperate, treatment can work. For example, every dollar invested in public substance abuse treatment returned over $5 in direct costs to taxpayers. Other significant findings from the report included:

• In the Multnomah County, Oregon STOP (Sanction Treatment Opportunity Progress) program, which provided court-monitored outpatient treatment, graduates averaged 0.4 re-arrests 2 years following com- pletion of the program, versus 1.5 re-arrests for people who were eligible to participate in the program but did not.

• Due to court-mandated treatment, for every dollar spent, $2.50 was saved in direct State and local government costs. Total savings including theft and costs to victims amounted to $10 per dollar spent.

• Positive drug tests in the workplace had increased since 1997, after they had decreased by almost half from 1993 to 1997.

• The percentage of adult arrestees testing positive for drugs was 67 percent in 2000. The percentage testing positive for drugs was similar across a wide variety of offenses.

• Alcohol-involved traffic deaths declined 28 percent statewide and 43 percent in Multnomah County between 1998 and 1999. Alcohol-related deaths are at their lowest level in over 20 years.

• Drug-related deaths dropped in 2000, both statewide (by 15 percent) and countywide (by 35 percent). Eighty percent of drug-related deaths in Multnomah County were heroin related.

Source: Regional Drug Initiative 2001.

proximity to offenders who use drugs and help the public recognize the benefits of treat- ment programs (e.g., jobs in the community, reduced crime, etc.).

Victims. Those victimized by a crime include the crime victim and family members—espe- cially children and significant others. Several States have passed constitutional amendments that protect the rights of victims and that usually provide an opportunity for the victim to take part in the criminal justice process. Additionally, community-based victims’ rights groups have been established in many com- munities, and some prosecutors’ offices employ victim advocates.

Victims have a variety of interests, depending on the circumstances of their cases. Most vic- tims want to see a combination of punish- ment, restitution, and protection, while oth- ers may be interested in having the offender’s substance abuse problem addressed. There are a number of “indirect” victims of drug- related crime who are not readily identified by law enforcement or the courts, such as individuals who live near “crack” houses and whose main goal is to close them down. As stakeholders, these victims should have the opportunity to represent their own interests.

Recovering criminal justice clients. Offenders in recovery are the “consumers” of treatment services. Although their criminal behavior creates public safety problems, often they are also the victims of abuse and other crimes. It is important to include criminal justice clients who are in recovery as stakeholders, since they are well informed about issues related to coordination between the justice and treat- ment systems. It is also important to refer- ence the statements, writings, achievements, and testimonials of recovering criminal justice clients.

Media. The media play a major role in shap- ing public attitudes toward the criminal jus- tice system, especially attitudes about how to handle substance-involved offenders. Avenues of communication between the media and the criminal justice and substance abuse treat-

ment systems must be kept open. Continual efforts should be made to communicate to the media a full picture of the multifaceted issues surrounding crime, substance use disorders, and substance abuse treatment. When media representatives are involved in planning, they may begin to see the positive side of joint efforts of the criminal justice and substance abuse treatment systems.

Legislators. Legislators should be consulted and provided up-to-date information about offenders who use substances and are involved with the criminal justice system. It is important that they also become aware of “success” stories, so that the influence of failed cases does not dominate their policy decisions. The political stance of being “tough on crime” and “waging war on drugs” has resulted in legislation requiring mandatory sentences for drug offenses, which must be tempered with information regarding positive treatment outcomes, the availability of effec- tive alternatives to incarceration, and the consequences of punitive approaches for drug offenders. Tough crime bills (e.g., “three strikes” laws) have resulted in high criminal justice expenses that often shift limited funds from social services and education to con- struction and operation of correctional facili- ties—actions that tend to exacerbate the crime problem and reduce the availability of needed services for citizens. In some cases, this type of punitive sentencing reform has been developed in reaction to a particularly heinous crime, with inadequate consideration provided to the public policy consequences.

Community organizations. Community groups include local boards, recreational programs, church groups, neighborhood watches, and other community associations that address, either directly or indirectly, the issues of sub- stance abuse and criminal behavior. These groups can play a role in prevention, treat- ment, and referral. Advocacy groups such as Mothers Against Drunk Driving and other special interest groups also can work effec- tively at the community level to address pre- vention issues. Their agendas often are con-

241Key Issues Related to Program Development

sistent with those of other community groups that can be helped to understand the impor- tance of reaching offenders with effective treatment.

Businesses. Local businesses and business groups, such as Kiwanis, Rotary, and down- town business associations, have a strong interest in preventing crime, since they may be targets, and often take an active role in their communities. Employers also are inter- ested in preventing substance abuse by their employees. Businesses are a vital component of the larger community and should be involved in planning for substance abuse treatment in the criminal justice system. Business leaders can provide invaluable assis- tance in planning training programs and pro- viding opportunities for job placements. Vocational training is a critical component of the transition and reintegration process for offenders with substance use disorders reen- tering communities (see also chapter 8 in TIP 38, Integrating Substance Abuse Treatment and Vocational Services [CSAT 2000c]).

The consensus panel believes that leaders from the criminal justice and substance abuse treatment systems can do the hard work of planning substance abuse treatment for offenders in all parts of the criminal justice system continuum. Policy, procedures, rela- tionships, and shared responsibilities should be developed to operationalize effective sub- stance abuse treatment within the criminal justice system.

Program-Level Coordination Federal, State, and local policies have a tremendous effect on the quality and availabili- ty of substance abuse treatment for offenders, as do policies and procedures within individual programs. The following sections address the barriers to effective program coordination and integrating substance abuse treatment into criminal justice at the program level.

Barriers to Program Coordination Farabee and colleagues (1999) identified six major barriers that prevent effective imple- mentation of substance abuse treatment in the criminal justice system. These barriers and their suggested solutions are summarized in Figure 11-2.

Program Components Effective programs include case management along with procedures to coordinate the flow of information and to serve the best interests of the offender.

Case management Case management is the process of linking the offender with appropriate resources; tracking the offender’s participation and progress in the referred programs; reporting this infor- mation to the appropriate supervising author- ity and, when requested, to the court; and monitoring the conditions imposed by the court. Effective case management often requires supplementary funding and realloca- tion of resources.

Case management activities optimally begin at the pretrial period, continue throughout the treatment process, and provide a means to coordinate the requirements of the justice system with treatment goals and other imme- diate concerns. Case management activities focus on coordination of services during tran- sitions between different stages of the justice system. When clearly defined, accountability guidelines established across the two systems ensure that information regarding criminal activity, infractions, and other critical inci- dents are reported in a timely and effective manner.

242 Chapter 11

243Key Issues Related to Program Development

Figure 11-2 Barriers to Effective Treatment

Problem Area Description of Problem Solution(s)

Assessment Assessment uses broad defini- tions of drug abuse and applies criteria unrelated to addiction. As a result, inmates are not always matched with the appro- priate level of services, and some inmates who do not have sub- stance abuse problems are placed in treatment.

Expand treatment options by establishing larger numbers of carefully targeted programs at more institutions.

Staff training Many newer prisons have been constructed in rural areas where local communities have a smaller pool of treatment professionals and fewer people in recovery as potential staff members.

Offer better wages; recruit and train offenders who are serving life sentences; and orient and train treatment staff and correc- tional staff together.

Staff redeployment Effective correctional officers and treatment counselors often move “up and out.”

Change rotation policies; certify and reward officers who wish to work in jail- or prison-based treatment programs.

Overreliance on institutional sanctions

In successful treatment pro- grams, noncompliant partici- pants face peer pressure and eventually develop internal con- trols. Often, however, institution- al sanctions are imposed before peers can have a positive impact.

Treatment and correctional staffs cooperate to determine condi- tions for imposing both therapeu- tic and institutional sanctions.

Aftercare Many participants drop out of treatment as soon as they can; many providers in the communi- ty hesitate to work with ex-pris- oners, especially those sentenced for violent or sexual offenses.

Establish treatment programs in the community that cater to or willingly accept parolees, proba- tioners, and others under com- munity supervision.

Coercion Often inmates do not volunteer for treatment because peers attach stigma to it, programs demand more rules and struc- ture, and participants often lose seniority and job opportunities in the facility.

Focus on rewarding good behav- ior. Remove disincentives and add such inducements as early release, better living quarters, and better job opportunities.

Source: Farabee et al. 1999.

Procedures to coordinate the flow of information Information management is the key to identi- fying treatment needs and can provide treat- ment and related services more effectively. Basic information gathered about the defen- dant should follow the offender through sub- sequent stages of the criminal justice system and substance abuse treatment system. Agencies from both systems should decide what information is necessary and useful and should develop methods for sharing that information. However, the defendant’s civil liberties and rights of confidentiality must be considered whenever information is shared.

Procedures to improve information flow include the following:

• Establish methods for timely collection and reporting of information.

• Implement regular quality control proce- dures to maximize completeness, accuracy, and consistency of data.

• Establish consistent definitions of the data elements between the different participating agencies.

• Ensure that information flows in both direc- tions: from treatment providers to criminal justice staff, and from criminal justice staff to treatment providers.

• Increase sensitivity to the confidentiality requirements and political concerns of criminal justice agencies and treatment providers.

• Create a designated central repository for appropriate client information.

Integrating Public Safety and Treatment at the Program Level Good substance abuse treatment programs contribute heavily to enhancing safety and security, as program participants usually pre- sent the fewest safety and security-related problems (Belenko 2001). Treatment and security can be thought of as two sides of the same coin, rather than as opposites. For

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Information Sharing: Maricopa County Data Link Project

An innovative approach to sharing information between the jail and community services is reflected in the Maricopa County (Arizona) Data Link Project (National GAINS Center 1999c). Computer experts developed an electronic data link between the Maricopa County Jail and the public mental health system to identify clients who have previously received mental health services. This link identifies mental health clients regardless of their charges, time of jail booking, or mental health status at the time of booking.

All jail admissions are electronically routed to the management information system (MIS) operated by the public mental health system, with the MIS automatically matching clients based on demographic and other identifying information. Clients identified as matches with the mental health system are immedi- ately “flagged” for the jail diversion program—an initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide triage, case management, and treatment services for nonviolent inmates who have co-occurring substance use and mental disorders. The jail diversion team then evaluates potential candidates for its program, based on public safety risk factors, current mental status, availability of community mental health and treatment resources for those with co-occur- ring disorders, and prior history in treatment services. Clients accepted into the jail diversion program may be released from jail under pretrial or deferred prosecution arrangements to participate in treat- ment as a condition of community supervision. The Data Link Project has enabled the jail to increase the number of inmates identified for diversion and treatment involvement by approximately 100 percent within the first year of operation.

example, substance abuse treatment signifi- cantly enhances offenders’ accountability through additional monitoring and communi- cation with the courts, community supervi- sion, and other criminal justice staff. Accountability also is provided by drug test- ing and by behavioral and skills-oriented interventions that are provided by treatment.

The consensus panel believes that the follow- ing conceptual model is helpful in under- standing how the justice system is strength- ened by substance abuse treatment involve- ment.

Supportive environment with accountability A key issue for criminal justice programs is how treatment and justice system staff can work together to maintain a positive atmo- sphere that supports offenders’ recovery efforts while confronting and managing offender “games” and manipulative coping strategies. Programs that focus exclusively on either supportive or confrontational approaches generally are not effective within the criminal justice system. Criminal justice treatment programs run smoothly and suc- cessfully only when staff employ both sup- portive and accountability procedures. “Confrontation” as used here does not mean a hard and aggressive verbal interchange, but rather assertively pointing out misbehavior and discrepancies between goals and behav- ior.

Some programs are successful in implement- ing only half of this formula. Supportiveness without accountability leads to the appear- ance that staff are trying to be “friends” with clients, leaving staff vulnerable to offender manipulation. The staff relationship with the client is better represented as that of a teach- er and student, with staff modeling adaptive skills, behaviors, and attitudes. Conversely, accountability procedures that are developed in a nonsupportive environment often lead to an atmosphere characterized by hostility and punitiveness. Criminal justice system pro-

grams with this type of atmosphere are not typically successful in engaging offenders in treatment recovery.

Justice system programs flourish when all staff contribute to both the supportive envi- ronment and accountability of the clients. Keys to success include staff appreciation of the need to set limits supportively and to establish clear personal boundaries with clients. A final point for all staff who are inte- grating the work of criminal justice staff and treatment staff is that good treatment is good public safety. Treatment staff should demon- strate to justice system staff how their pro- gram might enhance safety and security. Substance abuse treatment programs can quickly demonstrate their worth by effective- ly managing clients’ difficult behavior, sup- porting the work of criminal justice staff, and holding themselves and criminal justice staff accountable for following through with their respective commitments to the program.

Personnel needs Training and professional and workforce development issues are of paramount concern in implementation of treatment programs with the criminal justice system. Because the crim- inal justice system affects the environment in which treatment occurs and provides the structure to which the client must respond, substance abuse treatment counselors need to become familiar with the criminal justice sys- tem, its unique terminology, and methods of balancing client treatment needs with safety issues. Treatment professionals working with criminal justice clients should be knowledge- able about criminogenic risk factors, the most effective strategies and approaches for use with offender populations, and the need for professional boundaries.

By the same token, criminal justice staff should understand the goals of substance abuse treatment, the effects of frequently abused drugs, and the types of treatment that are available. Treatment knowledge is partic- ularly important for criminal justice staff,

245Key Issues Related to Program Development

since treatment is increasingly affecting all aspects of diversion, community supervision, court monitoring, and incarceration. Cross- training activities can encourage employees to work together. Training is also needed to address the wide variety of “special needs” populations under criminal justice super- vision and the impact of managed care sys- tems and tiered placement criteria (e.g., American Society of Addiction Medicine crite- ria) on publicly funded treatment systems.

Given that the rapid growth of treatment pro- grams within the criminal justice system has not been matched by equal growth in organi- zational and staff resources, the system has been strained. Staff turnover, burnout, and other occupational hazards can be addressed through efforts to increase professionalism, such as developing

• A clear hierarchy of staff positions with increasing responsibilities at each level

• Clear requirements for advancement in the hierarchy

• Incentives for additional training, made read- ily available

• Incentives for working on units that are con- sidered more difficult or are higher security

• Merit pay

Training resources CSAT launched a network of Addiction Technology Transfer Centers (ATTCs) in 1993 to increase the knowledge and skills of sub- stance abuse treatment professionals; to facil- itate access to state-of-the-art research and education; heighten the awareness, knowl- edge, and skills of all professionals who may be in a position to help people with substance use disorders; and to foster alliances among stakeholders. Information on and links to ATTC’s 14 Regional Centers and National Office can be accessed online at www.nattc.org.

The ATTCs have extensive resources of value to professionals working with offenders who

abuse substances, a few of which are high- lighted below:

Working with Criminal Justice Clients. Designed to familiarize substance abuse treat- ment counselors to work with criminal justice clients, the curriculum includes material on intersystem teamwork and relapse issues. (For further information or to order the material online go to www.neattc.org.)

Training for Professionals Working with MICA (Mentally Ill Chemical Abusing) Offenders. This 1-day course module serves as cross-training for staff in law enforcement, mental health, and substance abuse settings. (For further information or to order the material online go to www.neattc.org.)

Orientation to Therapeutic Community. Developed to introduce administrators and ancillary staff to the history, theory, and cur- rent research on the therapeutic community model, this training provides a fundamental framework for therapeutic communities. This training curriculum is not intended for front- line workers. (For further information or to order the materials online go to www.mattc.org.)

Therapeutic Community Experiential Training. Intended for frontline staff of start- up therapeutic communities, this 5-day inten- sive experiential training provides partici- pants with the knowledge, expertise, and atti- tudes that have been used effectively by pro- fessionals in the field. (For further informa- tion or to order the material online go to www.mattc.org).

Criminal Justice/Substance Abuse Cross Training: Working Together for Change. This program is designed to help administrators and professionals integrate criminal justice and substance abuse services systems to coor- dinate treatment and recovery services and overcome barriers to collaboration. (For fur- ther information or to order the material online go to www.mattc.org.)

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Research and Evaluation Research and evaluation is a critical dimen- sion of substance abuse treatment programs in the criminal justice system. Evaluations are needed for program monitoring and for decisionmaking by program staff, prison administrators, and policymakers. Evaluations provide accountability, identify strengths and weaknesses, and provide a basis for program revision. In addition, eval- uation reports are useful learning tools for others who are interested in developing effec- tive programs. Many treatment programs in the criminal justice system have operated without evaluations for many years, only to find out later that key outcome data are need- ed to justify program continuation.

Conducting an adequate evaluation requires one to clearly formulate the treatment model and reasonable program goals and specific objectives related to client needs. General goals must be translated into measurable out- comes. The evaluator generally works closely with program administrators to translate their evaluation guidelines into operational components. For example, general goals of helping program participants become drug and crime free can be operationalized into intermediate goals of changing behavior (e.g., reductions in rule infractions and fewer posi- tive drug test results) while in a program.

There are three basic types of evaluations:

1. Implementation

2. Process

3. Outcome

While implementation and process evalua- tions can begin when the program is initiated, outcome evaluation should not begin until the program has been fully implemented. Outcome evaluations are generally more cost- ly than other types of evaluation and are war- ranted for programs of longer duration that are aimed at modifying lifestyles (such as therapeutic communities), rather than drug

education interventions that are less intensive and less likely to produce long-term effects.

Implementation Evaluation While programs often look promising in the proposal stage, many fail to materialize as planned in the security-oriented correctional environment. Other programs are rigidly implemented as planned and without adjustments for the realities of prison, often rendering them less effective. Implementation evaluations are aimed at identifying problems and accomplishments during the early phases of program development for feedback to clinical and administrative staff. Such evalua- tions involve infor- mal and formal interviews with correctional administrators, officers, and inmates to ascertain their degree of satisfaction with the program and their perceptions of problems.

In order to initiate an evaluation, in addition to having a clear, detailed proposal that describes the planned program, evaluators will need to know

• The model or theory the program is based on

• Criteria for participation

• Program components

• Planned treatment duration

• Staff qualifications

• Plans for staff orientation and training

• The schedule for implementation

These elements provide the basis for assess- ment. Periodic implementation feedback

247Key Issues Related to Program Development

Research and

evaluation is a

critical dimension

of substance abuse

treatment

programs in the

criminal

justice system.

reports to program and institutional adminis- trators can be very useful in identifying prob- lems and planning corrective measures.

Process Evaluation Traditionally, process evaluation refers to assessment of the effects of the program on clients while they are in the program, making it possible to assess the institution’s intermediary goals. Process evaluation involves analyzing records related to

• Type and amount of services provided

• Attendance and participation in group meet- ings

• Number of clients who are screened, admit- ted, reviewed, and discharged

• Percentage of clients who favorably complete treatment each month

• Percentage of clients who have infractions or rule violations

• Number of clients who test positive for sub- stances (this can be compared to urinalysis results for the general prison population)

Effective programs produce positive client changes. These changes initially occur during participation in the program and ideally con- tinue upon release into the community. The areas of potential client change that should be assessed include

• Cognitive understanding (e.g., mastery of program curriculum)

• Emotional functioning (e.g., anxiety and depression)

• Attitudes/values (e.g., honesty, responsibility, and concern for others)

• Education and vocational training progress (e.g., achievement tests)

• Behavior (e.g., rule infractions and urinaly- ses results)

Within corrections it is also important to evalu- ate program impact on the host institution. Well-run treatment programs often generate an array of positive developments affecting the

morale and functioning of adjacent cellblocks and entire prisons. Areas to examine include

• Inmate behavior. Review the number of rule infractions, the cost of hearings, court litigation expenses, and inmate cooperation in general prison operations.

• Staff functioning. Assess stress levels, which may become manifest in the number of sick days taken and the rate of staff turnover. Generally, the better the program, the lower the stress, and the better the atten- dance, the involvement, and the commit- ment of staff.

• Physical plant. Examine the physical prop- erties of the program. Assess general van- dalism apparent in terms of damage to fur- niture or windows, as well as the presence of graffiti. Assess structural damage, for example, to walls and plumbing.

Institutional impact can be evaluated by com- paring the status of the environment before and after program implementation (pre/post comparison), as well as by comparing the cur- rent status of similar cellblocks that do not have treatment programs. Careful cost assess- ment of institutional impact can help provide convincing information regarding program cost benefits to administrators, funding sources, and policymakers.

Outcome Evaluation Outcome evaluations are more ambitious and expensive than implementation or process evaluations. Outcome evaluations involve quantitative research aimed at assessing the impact of the program on long-term treatment outcomes. Such evaluations are usually care- fully designed studies that compare outcomes for a treatment group with outcomes for other less intensive treatments or a no-treatment control group (i.e., a sample of inmates who meet the program admission criteria but who do not receive treatment), complex statistical analyses, and sophisticated report prepara- tion.

248 Chapter 11

Followup data (e.g., drug relapse, recidivism, employment status) are the heart of outcome evaluation. Followup data can be collected from criminal justice and substance abuse treatment agency records or from face-to-face interviews with individuals who participated in prison programs. Studies that use agency records are less expensive than locating for- mer inmates and conducting followup inter- views. Outcome evaluations can include cost- effectiveness and cost-benefit information that is important to policymakers.

Because outcome research usually involves a relatively large investment of time and money, as well as the cooperation of a variety of peo- ple and agencies, it must be carefully planned. A research design may be very sim- ple and easy to implement or it may be more complex. In the case of more complex studies it is usually advisable to enlist the assistance of an experienced researcher. The kinds of outcome information that might be collected are summarized in Figure 11-3 (next page).

There is a hierarchy of evaluation approaches ranging from simple outcome monitoring to nonrandom or quasi-experimental designs to experimental research studies that use ran- dom assignment. The selection of a research design depends on available funding and available comparison groups.

Any claims to a program’s effectiveness rest on comparisons that demonstrate it is superi- or to nontreatment groups or to groups that have received another type of treatment. The power of a research design is related to how defensible study results are against potential criticisms. Although simple outcome monitor- ing studies are relatively economical to con- duct, they lack the comparison groups needed to show the specific effects of a program. While specific program outcomes can be com- pared with national and State norms or with published outcomes of another program, such comparisons are limited because of the many uncontrolled potential differences between

the program group being monitored and the comparison groups.

The defining characteristic of a pure research design is random assignment of inmates to treatment and control groups. Random assignment may be done by using a lottery type procedure that ensures that there are no systematic pretreatment differences between the groups (such as motivation or background characteristics). The concern is that any important preprogram difference in program and control groups may bias the results and compromise any claims for program effective- ness. Random assignment is difficult to imple- ment in prisons because of ethical and legal implications of denying inmates treatment. If a program has a substantial waiting list it may be feasible to implement a lottery procedure as a fair method to control program admis- sion, thus creating a random assignment situ- ation.

Nonrandom assignment is an attempt to approximate the power of the pure experi- mental design. A popular quasi-experimental design uses a comparison group that is matched to the program group on as many pretreatment factors as possible. Often, sta- tistical methods are employed to control pre- treatment group differences that might influ- ence outcomes.

Locating criminal justice clients for outcome studies is a very difficult and expensive undertaking. Collection of extensive locator information at program intake will assist interviewers in the locating task. Examples of useful locator information include social secu- rity number, driver’s license number, moth- er’s maiden name, aliases, names and loca- tions of family members and friends, and locations of favorite hangouts.

Large samples are needed in outcome studies to demonstrate significant results and to study the effects of multiple variables. For example, an analysis of the role of ethnicity (African American, Caucasian, and

249Key Issues Related to Program Development

Hispanic/Latino) reduces group size by a third. When reporting results it is generally best to use less complex statistics such as per- centages and averages so that they are clear and understandable to nonstatisticians. Often, showing results in figures and charts is helpful. It is advisable to keep reports concise and clear for policymakers who may have lit- tle time or patience to study complex materi- al. Finally, the credibility of outcome studies is often enhanced when conducted by outside researchers who have fewer vested interests in the outcomes.

The consensus panel provided several recom- mendations for improving evaluation efforts within criminal justice programs:

• Management information systems should be coordinated for use by substance abuse treat- ment and justice system professionals. This can lead to greater sharing of information and ensure that information is available for evaluation purposes.

• Quality assurance and quality improvement measures should be applied across all crimi- nal justice program settings.

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Figure 11-3 Outcome Information

Drugs • Urinalysis results

• Drug-related parole infractions

• Drug-related arrests

Crime • Parole rule infractions

• Time until parole rule infraction

• New misdemeanor arrests of any type

• New felony arrests for non–drug-related crimes

• New felony arrests for drug-related crimes

• New felony arrests for violent crimes

• Time until arrest

• Re-incarceration

Social adjustment • Employment and education

• Family (e.g., support, child rearing, marital, etc.)

• Substance abuse treatment

• Community involvement (e.g., community service)

HIV risk behaviors • Intravenous drug injection

• Sexual behavior

• HIV test results

Cost information • Cost estimates of substance use

• Cost estimates of crimes

• Cost estimates of social services to family (e.g., welfare)

• Criminal justice processing and detention costs

Tracking information • Tracking locator information (e.g., social security and license num- bers, addresses of family and friends, etc.)

• Monitoring and evaluation should be part of all major treatment initiatives established within the criminal justice system.

Cost Issues Another critical area in program development is that of program costs, including cost sav- ings and cost-benefit/cost-offset information. Program administrators are routinely required to provide evidence that monies are spent effectively. The literature indicates that treatment has cost benefits in certain settings. Positive cost-offset results (savings down the road) have been demonstrated from treat- ment through specific approaches, such as drug courts (Belenko 2001). Similar results have been shown for treatment in prison set- tings (McCollister and French 2001).

Cost analyses (see Figure 11-4 below for defi- nition) are important in determining how to allocate funds within a program and for understanding the relationship between costs and outcomes. Examining costs for the pro- gram as a whole (or for parts of it) is a basic form of cost analysis. Cost analyses can be provided as a monthly or quarterly report and costs generally vary over time. Costs pro- vided at several levels include:

• Total cost of the program for the average treatment

• Cost of each part of the program each day

• Total monthly or annual cost per offender

The major types of cost analyses include “cost,” “cost-effectiveness,” and “cost benefit,” and are described below in Figure 11-4.

Some treatment program evaluations measure direct monetary outcomes, such as a reduc- tion in the use of health services. Other treat- ment program evaluations can measure indi- rect costs, such as reduction in crime-related costs, reduced recidivism, and the costs of incarcerating offenders.

Other ways to report the relationship between costs and benefits include

• The net benefit of a program can be shown by subtracting the costs of a program from its benefits.

• The ratio of benefits to costs is found by dividing total program benefits by total pro- gram costs.

• The time to return on investment is the time it takes for program benefits to equal pro- gram costs.

• The present value of benefits takes into account the decreasing value of benefits attained in the distant future.

• Because neither net benefits nor cost-benefit ratios indicate the size of the cost (initial investment) required for treatment to yield the observed benefits, it is important to report this as well.

251Key Issues Related to Program Development

Figure 11-4 Definition of Terms

Name Definition

Cost analysis A thorough description of the type and amount of all resources used to produce substance abuse treatment services.

Cost-effectiveness analysis The relationship between program costs and program effective- ness, that is, patient outcome.

Cost benefit analysis The measurement of both costs and outcomes in monetary terms.

Source: Yates 1999.

Key Goals of SAMHSA SAMHSA is committed to serving justice- involved populations and shares that responsi- bility with other agencies. In 2004 SAMHSA began a 2-year action plan to create a strategy to facilitate development and management of mental health and substance abuse prevention, early intervention, clinical treatment, and recovery support policies, programs, strategies, and practices for adults and juveniles in con- tact with or involved with the justice system. Following are some of the key activities that are underway:

• Develop and implement a Recovery Management Framework that will foster resiliency and manage recovery among adults and juveniles involved in the crimi- nal justice system.

• Examine the gaps within SAMHSA’s crimi- nal and juvenile justice activities and iden- tify key efforts that could be implemented.

• Provide training and technical assistance on best practices and evidence-based programs for persons in the criminal justice system.

• Support mechanisms that promote science- based policies, programs, and models to

ensure that services are provided at all points in the criminal justice system.

• Support knowledge synthesis and informa- tion dissemination efforts to help change attitudes of and reduce stigma among ser- vice providers who work with clients in the justice system.

• Engage in targeted collaborations at local, State, and Federal levels to promote effec- tive, integrated systems approaches.

• Inform communities, policymakers, and other stakeholders of the importance of substance abuse and mental health services for people in the criminal justice system.

For more information about SAMHSA’s efforts regarding substance abuse and mental health services for adults and juveniles in the criminal justice system go to www.samhsa.gov.

Conclusions The consensus panel draws conclusions and makes recommendations as follows:

• A goal that is critically important to both the substance abuse treatment and correctional systems is the reduction of crime.

252 Chapter 11

How Politics and Policy Can Affect Treatment: California’s Proposition 36

In November 2000, by a 60 percent majority, California passed Proposition 36 (the Substance Abuse and Crime Prevention Act [SACPA], see chapter 7 for more information). Its passage has been inter- preted, in part, as an expression of public dissatisfaction with the increasing share of State budgets allo- cated to expansion of correctional facilities at the expense of other public services, such as education.

Under the SACPA initiative, offenders who are convicted of nonviolent drug-related offenses are eligible for diversion to community treatment programs. Diversionary program eligibility is also provided for an estimated 9,500 parole violators annually. Offenders may apply to have their charges dismissed after successful completion of probation and treatment. Proponents of this law suggest that treatment saves money and enhances public safety and public health by reducing crime and substance abuse. Opponents countered that the proposition offers a quick fix that lacks safeguards, compromises public safety, and invites ineffective treatment. The law became effective July 1, 2001. In its second year (July 2002 to June 2003), about 50,000 offenders were referred for substance abuse treatment. Of those, about 71 percent (35,947) went on to enter treatment (Longshore et al. 2004).

• It is vitally important that these two systems recognize that treatment must be tailored to the particular criminal justice setting and to the client’s stage in the recovery process.

• The following basic principles can be used to promote change in the criminal justice and treatment systems: developing leadership, obtaining endorsement from systems leaders, establishing common goals and objectives, identifying stakeholders, and encouraging collaboration among stakeholders.

• Good treatment programs contribute to enhancing safety and security, as program participants usually present the fewest safety and security-related problems.

• Substance abuse treatment professionals should be trained in criminal justice issues, and criminal justice personnel should be

trained in substance abuse issues. Cross- training activities can encourage employees’ willingness to work with each other more and can help personnel manage the wide variety of “special needs” populations under crimi- nal justice supervision as well as the impact of managed care systems and tiered place- ment criteria.

• Research and evaluation are a critical dimen- sion of substance abuse treatment programs in the criminal justice system. Evaluations provide feedback related to key issues and also can identify major problems related to program implementation.

• Program costs are another critical area. Cost analyses can help a program determine how to allocate funds and understand the rela- tionship between costs and outcomes.

253Key Issues Related to Program Development

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Center for Substance Abuse Treatment. Substance Abuse Among Older Adults. Treatment Improvement Protocol (TIP) Series 26. DHHS Publication No. (SMA) 98-3179. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998c.

Center for Substance Abuse Treatment. Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities. Treatment Improvement Protocol (TIP) Series 29. DHHS Publication No. (SMA) 98-3249. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998d.

Center for Substance Abuse Treatment. Brief Interventions and Brief Therapies for Substance Abuse. Treatment Improvement Protocol (TIP) Series 34. DHHS Publication No. (SMA) 99-3353. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999a.

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Center for Substance Abuse Treatment. Screening and Assessing Adolescents for Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 31. DHHS Publication No. (SMA) 99-3282. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999c.

Center for Substance Abuse Treatment. Treatment of Adolescents With Substance Use Disorders. Treatment Improvement Protocol (TIP) Series 32. DHHS Publication No. (SMA) 99-3283. Rockville, MD: Substance Abuse and Mental Health Services Administration, 1999d.

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