Successful collaboration among the substance abuse treatment
system, the public health system, and the criminal justice system
requires that practitioners in each system understand the values
and perspectives of the other systems. Effective systems integration
depends on practitioners' ability to
Develop and clearly state shared goals
Jointly obtain, exchange, and use information
Engage in ongoing communications about individual cases and
systemic issues
Develop operational procedures that meet the needs of the
individuals in treatment and take into account the available
resources of the participating institutions
Perhaps most importantly, exercise strong leadership within
each system.
This chapter describes the values and perspectives of each
of the collaborating systems and discusses each of the areas
listed above. This discussion will help practitioners in all
systems integrate substance abuse treatment in the pretrial processing
of criminal cases.
Significant differences in the philosophies, activities, and
structure of the three systems pose a challenge to collaboration,
as do the differences in goals, values, and approaches to specific
problems. However, there are some important values that are broadly
shared by practitioners who work within the substance abuse treatment,
public health, and criminal justice systems.
The justice system is based in law, state and local procedures,
and the local legal culture. Courts are at the center of the
adjudication process, which in criminal cases is typically adversarial.
Charges are brought by a prosecutor on the basis of evidence
gathered by the police or another law enforcement agency. The
defendant is usually represented by a defense lawyer, required
if the charges are serious enough that they could result in incarceration
upon conviction. A judge presides over court proceedings in
the case. The judge
Advises defendants of their rights
Sets conditions of pretrial release
Conducts hearings and trials and determines guilt or innocence
Sentences defendants who plead guilty or are found guilty
after trial.
The judges, prosecutors, and defense lawyers who work in the
criminal courts naturally approach a case involving a substance-abusing
individual as a legal matter. The nature of the defendant's substance
abuse problem is, if it is discussed at all, a secondary issue.
The primary focus is on the defendant's guilt or innocence with
regard to the criminal charges that led to arrest and prosecution.
The differences between the two types of courts are summarized
in Exhibit 2-l.
However, while the criminal laws and related public safety
concerns are important for justice system practitioners, they
are by no means the only values that influence the operation
of the system. Other broadly shared goals include
Due process. Justice system practitioners
place a high value on both the appearance and the reality of
even-handedness in the administration of justice. This means
that defendants charged with the same offense who have similar
criminal records and other relevant characteristics in common
will be treated in a consistent fashion.
Protection of individual rights. Defense lawyers
have a special role as guardians of a defendant's legal rights.
All justice system practitioners are concerned with upholding
these rights -- including the right to representation of counsel
and the right to make informed choices about available alternative
courses of action during the pretrial process.
Expeditious resolution of cases. The swift resolution
of cases is important for victims, defendants, and the public.
Systemic delay can undermine the court's credibility, lessen
the quality of justice, and impair the court's ability to take
on new programmatic initiatives.
Appropriate disposition. While practitioners with
different roles and responsibilities may disagree about the appropriate
disposition of a particular case, they tend to view the relative
severity of different offenses and appropriate dispositions for
particular types of criminal conduct roughly the same way. Of
particular relevance for this Treatment Improvement Protocol
(TIP), there appears to be an emerging consensus among justice
system practitioners that prison is a scarce resource, best used
for individuals who are genuine threats to public safety. There
is a growing awareness that incarcerating individuals for drug
use or possession may not be an effective use of prison space
and that substance abuse treatment has a far greater likelihood
than incarceration of reducing future criminal behavior by addicted
individuals.
The treatment system's primary purpose is to end or alleviate
a client's substance abuse. Practitioners in the system generally
adopt a health promotion/disease prevention model in which the
treatment professional works with the client to overcome what
is seen as a biopsychosocial disease or disorder. The term biopsychosocial
is used to indicate that biological, psychological, and social
factors are deeply woven into the development of addiction.
These factors must be addressed in order for treatment to succeed.
Substance abuse treatment practitioners recognize that some
types of substance abuse involve possession and use of illegal
drugs, but their primary concern is not with the illegality of
the activity; rather it is with the recovery from addiction.
Substance abuse generally becomes more severe over time; if
left untreated, the disease can be fatal. Substance use disorders
cannot be "cured," but many individuals can make the behavioral
changes necessary to recover.
The treatment community recognizes that relapse is a common
feature of addiction. Indeed, relapse -- a return to addictive
behavior -- may sometimes be a step (or misstep) on the path to
recovery, rather than a failure. It is not uncommon for an individual
to alternate between treatment and relapse before completely
recovering.
Treatment practitioners note that the progression of the severity
of substance abuse can be depicted on a continuum that ranges
from experimentation at one end to recovery or death on the other.
The goals of treatment, which apply to every stage of the continuum,
are
To reduce the incidence and prevalence of the chronic,
progressive abuse of alcohol and other drugs
To provide a system of services to assist people, their families,
and communities in recovering from addiction
To decrease the number of people at risk for addiction.
Matching people to the appropriate level of care and providing
a range of support services (for example, medical care, child
care, housing, job training, and aftercare) are key elements
of the treatment process. Support services allow individuals
to make effective use of substance abuse treatment. Careful
assessment both of the person's severity of addiction and of
the range of problems related to substance use, such as medical
illness, family and social problems, legal problems, and lack
of adequate housing and nutrition, is critical to client-treatment
matching. Successful treatment generally includes some form
of supportive, drug-focused individual and/or group counseling
to identify relapse triggers and provide long-term support.
Self-help groups, such as Alcoholics Anonymous and Narcotics
Anonymous, while not considered treatment, help many successfully
recover.
Services provided to people at different stages of the disease
can be divided into three categories: (1) pretreatment services
(prevention, including education about the dangers of substance
abuse), (2) outpatient treatment, and (3) inpatient treatment
(including residential treatment). Most drug courts target services
for persons in the latter two stages, although prevention services
may be provided for those who are minimally involved in drug
use. For a more detailed description of treatment approaches
and modalities, see Chapter 4.
Public health practitioners are focused on the health of entire
communities. Indeed, public health can be defined as organized
community activities that promote the improvement of physical,
occupational, behavioral, and social health. The public health
system is grounded in an epidemiological approach that studies
the determinants of disease and health risks, their distribution,
and the incidence of disease across and within population subgroups.
It is a "big picture" approach quite different from the focus
on individual clients or defendants that is characteristic
of many substance abuse treatment and justice system practitioners.
Public health goals include health promotion and disease prevention,
which depend on the interrelationship of health and social service
agencies. The early stages of criminal case processing present
a valuable point of public health intervention, because many
people arrested have substance abuse problems accompanied by
infectious disease. Well-designed screening to identify criminal
defendants with substance abuse problems can also help identify
defendants who have HIV/AIDS, other sexually transmitted diseases
(STDs), TB, and hepatitis B. Referral to treatment will not only
help such defendants, it will also help prevent further spread
of these diseases.
Values inherent in one of the three systems sometimes conflict
with those of another. For example, two of the best-known harm
reduction strategies advocated by some public health professionals
are needle exchanges for addicts and condom distribution, both
designed to prevent the spread of HIV and other sexually transmitted
diseases. Many people within justice agencies believe these public
health programs condone illegal drug use.
Similarly, some substance abuse treatment programs have a
"controlled use" orientation. A provider in such a program may
condone or even applaud a client moving to a lower level of drug
use or reducing frequency of use. However, when the drug being
used is an illicit one, a controlled use orientation may be unacceptable
to criminal justice agencies.
Problems can arise when courts, criminal justice agencies,
and other public institutions form partnerships with treatment
agencies and adopt harm reduction strategies that are not acceptable
to some groups in the community. Such situations can be difficult
for justice system leaders, especially if the goals and operational
procedures of all the partners are not clearly understood before
agreements are signed.
Given the range of values and philosophical world-views,
it is critical that leaders in each system understand each other's
values, perspectives, and priorities. Only then can policymakers
and practitioners develop a set of shared goals. The process
of developing shared goals compels policymakers to think through
the reasons for instituting the program, assess what can be accomplished
with the available resources, and consider what structural and
procedural changes may be necessary for the success of the program.
The potential benefits of integrating substance treatment with
pretrial case processing can be a starting point for developing
shared program goals.
Following are the five goals of collaborations among the
treatment, justice, and public health systems:
Reduced criminal behavior: fewer repeat offenders
Better use of limited jail space: fewer addicted prisoners
and more jail space for those who pose public safety risks
Improved delivery of treatment services: more effective
treatment for a significant population of substance abusers
Effective disease prevention and treatment: better health
status for substance abusers as well as prevention and treatment
of infectious diseases
Improved productivity: greater employment and reduced dependence
on social services and health systems.
In setting goals and developing program structure and operational
procedures, planners need frequently updated information from
all three systems -- the justice system, the treatment system, and
the public health system.
Timely and accurate information is especially important for
programs that provide treatment intervention in the pretrialstages of criminal cases. The immediate post-arrest period
is a time when critical justice system decisions are made about
a defendant, including decisions about specific charges to be
filed, conditions of custody or release, and appointment of defense
counsel. To enroll a person who has been arrested in a substance
abuse treatment program, everyone involved -- especially the court,
the prosecutor, the defendant, and defense counsel, and the treatment
provider -- will need accurate information on some key topics:
The nature and circumstances of the current charge
The defendant's criminal record
The status of any pending cases
The nature and severity of the defendant's substance abuse
problem(s)
The defendant's treatment history
The defendant's mental and physical condition, including
the presence of any infectious diseases
Based on the information gathered, the availability of a
treatment "slot" appropriate for the defendant.
Obtaining such information can be a challenge under any circumstances,
and it is a major challenge to do so in the 24- to 72-hour period
advocated by proponents of rapid treatment intervention. However,
as a number of jurisdictions have demonstrated, it is possible.
According to a recent American University survey, the following
treatment drug courts screen dependents within 72 hours and begin
assessment and treatment intervention within 1 day: District
of Columbia (Superior Court); Fort Lauderdale, Florida; Kalamazoo,
Michigan; Las Vegas, Nevada; Seattle, Washington; and Kansas
City. It is also possible to design information systems that
give everyone involved quick access to information on defendants'
performance in treatment and their compliance with other conditions
of release set by the court. This rapid transfer of information
allows both systems to manage cases and interested parties to
follow the program's and individuals' progress.
Traditionally neither courts, criminal justice agencies, nor
substance abuse treatment providers have shared information like
this, so they must all move forward carefully. Information transfer
must abide by confidentiality laws designed to protect privacy
of individuals (see Chapter 8), and it may
require investment in computer hardware and software. When
the commitment to share information is made, as it has been in
some jurisdictions, the benefits -- in terms of sound program management
and informed decision-making -- are enormous.
In studies of corporate and public sector innovation and excellence,
effective leadership consistently emerges as a critical factor.
It will undoubtedly be a key factor in the success of any program
aimed at integrating substance abuse treatment with pretrial
case processing.
In this context, it is important to emphasize the necessity
of collaborative leadership. While individual judges
and prosecutors led the way in establishing most of the successful
the drug court programs, they were supported by a wide range
of individuals in top and middle management positions in the
courts, other justice system agencies, the treatment community,
and other public and private institutions.
Leadership in this area is not limited to the top managers
of the institutions involved. There is plenty of room for leadership
at middle management levels, too -- in the courtroom, in treatment
clinics, in public health agencies, and in the broad array of
criminal justice, educational, and social services agencies that
become involved in a comprehensive approach to treating the substance
abuse problems of defendants in criminal cases.
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