The general policies and plans developed during the initial
planning stage must eventually be shaped into a design for a
fully operational drug court. This chapter focuses on nine key
issues that must be addressed during the design stage:
Screening
Assessment
Determining categories of care and components of treatment
Detoxification practices
Program admission criteria and procedures
"Relapse" policies and judicial supervision of the defendant's
progress in treatment
Screening is a process used to determine whether an individual
is a likely candidate for participation in a treatment program
or needs other types of attention. Typically, a program that
links substance abuse treatment with pretrial case processing
will be limited to defendants who meet certain criteria with
respect to the nature of their substance abuse problems, the
current charges pending, and their criminal records.
Screening has three purposes:
To identify individuals who have substance abuse problems
that may warrant treatment
To identify individuals who have infectious diseases
To identify individuals who fit within the target population
of the program in terms of criminal justice criteria.
It is important to recognize that substance abuse and infectious
disease screening is not the same as a comprehensive assessment.
Screening is done quickly, using relatively simple instruments
and methods. A screening instrument does not provide enough
information for a clinical diagnosis; rather, it indicates the
probability that a particular condition, say, chronic
alcohol abuse or TB or a STD, is present. The goal of screening
is to quickly identify potential candidates for treatment intervention.
Criminal justice screening serves different purposes. Its
principal function is to determine the defendant's eligibility
for pretrial release or diversion programs linked to substance
abuse treatment. Ideally, screening in all three areas, for
substance abuse treatment, for infectious disease, and for criminal
justice program eligibility, will take place within 24 hours
of the defendant's arrest.
Substance abuse screening is a preliminary gathering of information
to determine if an individual has a problem with substance abuse
and, if so, whether a comprehensive clinical assessment is appropriate.
Personnel doing the screening do not have to be social services
professionals, but effective screening does require training.
The screening can be done quickly (no longer than 20 minutes)
with standard screening instruments. The substance abuse screening
process typically involves eliciting responses to questions in
five areas:
Consumption patterns -- the frequency, duration,
and quantity of substance abuse
Feelings of loss of control related to substance abuse
Extent of physical consequences of substance abuse
Experience with physiological problems related to
withdrawal from substance abuse
The individual's recognition of problems related to
substance abuse.
In addition to interviews or self-administered screening instruments,
screening should also include urinalysis, observation of physical
signs (such as obvious inebriation or needle tracks) and a review
of the individual's criminal history to see if it includes drug
use or possession.
The most common substance abuse screening instruments used
in treatment programs in the criminal justice system are
The CAGE questionnaire
Short Michigan Alcohol Screening Test
Substance Abuse Screening Instrument
Offender Profile Index
AIDS Initial Assessment Jail Supplement
SALCE (Substance Abuse Life Circumstances Evaluation).
Most of these instruments are described and included as Appendix
C in TIP 7, Screening and Assessment for Alcohol and Other
Drug Abuse in the Criminal Justice System(CSAT,
1994a).
There are not as many screening instruments for infectious
diseases as for substance abuse, but the Center for Substance
Abuse Treatment (CSAT) has developed a prototype infectious disease
screening instrument that can be used in conjunction with substance
abuse screening. Designed primarily to help identify individuals
who may have infectious diseases that are significant public
health problems (especially TB, HIV/AIDS, and STDs), the instrument
can be administered in about 15 minutes. The results can be
used both to help determine suitability for participation in
a court-linked substance abuse treatment program and as a basis
for referral to a health care facility for further infectious
disease assessment and treatment (regardless of whether the defendant
enters the substance abuse treatment programs). The prototype
instrument is described in detail in TIP 11, Simple Screening
Instruments for Outreach for Alcohol and Other Drug Abuse and
Infectious Diseases(1994c). However,
elements of the prototype instruments can be used for making
an assessment about defendants' STD risk. TIP 6, Screening
for Infectious Diseases Among Substance Abusers(CSAT, 1993b) can also be useful to planners.
Eligibility screening for a treatment program linked to pretrial
case processing necessarily involves attention to not only to
the current charge but also to the defendant's prior criminal
history. Often, the criteria for admission to a program will
be restricted to defendants facing only particular types of charges,
for example, drug possession or driving under the influence.
Admission to a program may also be restricted to individuals
with no past convictions for violent offenses and no currently
pending charges involving violence. Sometimes programs may exclude
individuals currently on probation or parole.
Screening related to criminal justice eligibility ordinarily
involves examination of arrest and complaint papers relating
to the current charge and review of criminal history data available
through local, State, and sometimes national criminal records
repositories. It may also involve an interview with the defendant
and contacts with the defendant's family or others in the community
to determine whether or not the defendant has a place to live
if released from custody.
Screening personnel do not need to be highly trained social
service professionals. It is important, however, that substance
abuse treatment professionals or criminal justice program staff
responsible for screening functions be well trained in the use
of screening instruments and other methods of identifying substance
abuse problems and risk factors for infectious diseases.
Criminal justice personnel can be trained to do some or all
of the initial screening. Optimally, the screening will be done
before the defendant's initial court appearance. Personnel from
any of the following agencies (or a combination of them) can
do the screening:
The law enforcement agency that makes the initial
arrest and does the booking
The sheriff's department or other agency in charge of the
jail
A pretrial services agency
A TASC (Treatment Alternatives to Street Crime) agency that
works with the court
Interviews with a defendant about substance abuse and infectious
diseases should be accompanied by a clear explanation of the
purposes of the interview, the defendant's rights regarding confidentiality,
and any limits on the confidentiality of information obtained
through the interview. The screening interviews should be conducted
in private, preferably by non-uniformed persons trained in cultural
competency as well as in substance abuse and infectious disease
screening methods. Screeners should be supervised by program
managers to ensure consistency and quality, and to make sure
that they are aware of the program's current eligibility and
suitability criteria.
While screening is focused on program eligibility and on potential
substance abuse and infectious disease problems, assessment is
a more comprehensive set of procedures, intended to confirm or
refute the results of the initial screening, identify the specific
substance being abused , any coexisting health problems -- particularly
mental health disorders -- and begin formulating a treatment plan.
For more information on coexisting mental illness and substance
abuse disorders, see TIP 9, Assessment and Treatment of Patients
With Coexisting Mental Illness and Alcohol and Other Drug Abuse(CSAT, 1994b). One assessment instrument
used by substance abuse treatment professionals is the Addiction
Severity Index (ASI), which must be administered by a clinician
and takes an hour. The assessor develops and analyzes information
about the nature and extent of the defendant's substance abuse
history, mental and physical health problems, social and economic
status, and readiness for treatment. The types of treatment
and ancillary services required to address the problems are
then identified.
A comprehensive assessment for substance abuse treatment is
a thorough evaluation of the individual, using multiple procedures
and sources of information, to establish the presence or absence
of a diagnosable disorder or disease and lay the clinical foundation
for treatment.
Ordinarily, a clinical assessment addresses issues in three
broad domains of an individual's life: social, psychological,
and medical. Each of these domains includes a number of specific
components.
Elements to assess in the social domain include
History of substance abuse, including drugs
used, frequency and pattern of use, previous treatment, and drug-using
patterns in the family
Involvement with the criminal justice system, including
prior criminal history and any pending charges
Family history and social roles, including the individual's
roles in the immediate and extended family, as well as employment
status
Educational and vocational needs
Employment and salary history (socioeconomic status)
Spirituality, including the offender's sense of community
and "sense of belonging in the universe"
Experiences with domestic violence and child abuse/neglect.
Components of the psychological domain include
Level of psychological development
Levels of anxiety and depression
Risk of and/or history of prior treatment for mental illness
Use of any medication for mental health purposes
Presence of personality disorders or other mental
disorders
Central nervous system function and impairment
History of sexual, emotional, and/or physical abuse
History of violent behavior.
Areas to assess in the medical domain include
Risk of and/or history of infectious and contagious
diseases, including HIV, hepatitis, STDs, and TB
Medical problems, including nutritional deprivation,
and dental problems. A medical examination should be conducted
to determine health status. Tests for the presence of infectious
diseases also should be conducted.
Program personnel must follow State and local laws and regulations
when developing assessment questions concerning health issues.
In some States, for example, asking questions about HIV/AIDS
status is illegal or subject to laws and regulations concerning
confidentiality. On the other hand, some states, such as Arizona,
require that injection drug users be tested for HIV.
The information gathered usually is written up as a summary
statement that integrates the information acquired, the diagnostic
impressions of the assessor, and the recommendations for treatment.
Unlike screening, assessment requires substantial experience
in clinical settings. Ordinarily, the person doing the assessment
should have a master's degree and clinical experience. Psychologists,
social workers, certified addictions counselors, and clinical
nurses are among those qualified to administer the psychological
and sociobehavioral parts of the assessment. The biomedical portion
of the assessment is usually best performed by a health professional
with training in diagnostic skills, such as a physician, nurse,
or physician's assistant.
The justice system in the jurisdiction may already have personnel
who can conduct portions or perhaps all of a clinical assessment.
For example, some pretrial service agencies, TASC programs,
probation departments, and local jails have social services and
health professionals on staff who are qualified for this work.
In addition to an appropriate educational and clinical background,
staff responsible for the assessment should be culturally competent
and should have skills in establishing rapport with the defendant;
maintaining a nonjudgmental, nonthreatening attitude; and succinctly
documenting information.
An assessment should follow arrest as quickly as possible -- a
primary treatment objective is to take advantage of this crisis
in a substance abuser's life. Further, judges and prosecutors
are concerned about the expeditious processing of cases. If
a defendant is to be considered for deferral of prosecution and
placement in treatment, information about his or her treatment
needs must be readily available.
As a rough standard, many jurisdictions that have developed
drug courts in recent years attempt to place eligible defendants
in treatment 1 to 2 days following arrest. However, in order
to provide effective treatment services, a longer period may
be needed for a complete assessment. The scope and timing of
the assessment are critical issues in the design of a drug court
program, and should be a subject of discussion and negotiation
among the treatment providers and justice system leaders. It
may be possible to develop a two-stage assessment process, an
initial step that provides information needed by the court for
its basic decision about referral to treatment (more than initial
screening; less than full-scale assessment), and a second stage
that provides more complete information, enough for the treatment
provider to make a specific referral and for the court to monitor
the defendant's performance in treatment.
The treatment field uses numerous questionnaires and instruments
to collect information from the substance user. Two of the best
known are the
Addiction Severity Index (ASI), which requires
about 60 minutes to administer and is available from the National
Institute on Drug Abuse.
Wisconsin Uniform Substance Abuse Screening Battery,
which requires a fee for use, but which provides comprehensive
data.
The Fifth edition of the ASI is reprinted in TIP 7,
Screening and Assessment for Alcohol and Other Drug Abuse
Among Adults in the Criminal Justice System(CSAT, 1994a), which also includes instruments for assessing
AIDS risk and for determining the appropriate type of substance
abuse treatment. That TIP also describes a number of other instruments
used for assessment.
All assessment questionnaires have strengths and weaknesses,
and treatment professionals' preferences are based on particulars
from clients' situations to communities' needs. Many programs
cobble together parts of various instruments.
One way to select an assessment instrument or group of instruments
is to form a focus group of local treatment professionals who
understand the target population and the cultures of individuals
who routinely come before the court to select the treatment instrument(s).
Culture-specific instruments should be reviewed by people knowledgeable
about the culture to ensure that the questionnaires ask the target
group the right questions and are not skewed to misinterpret
behaviors of minority cultures as aberrant. Instruments should
be translated into the language of the population(s) being
assessed.
At each stage in the processing of criminal defendants, those
doing the screening and assessments must balance the risk
to public safety against the treatment needs of the
client. This risk/needs assessment should be incorporated into
a mutually reinforcing supervision and treatment plan. That
plan should include incentives and graduated sanctions as part
of supervision as well as treatment interventions and social
services that constitute a continuum of care.
The assessment should lead to a diagnosis of the extent and
severity of addiction and the problems it has created in the
individual's life. It should also lead to a treatment plan,
agreed to by the treatment provider and the individual and approved
by the court, that states specific goals for recovery and outlines
steps to begin and maintain the recovery process.
Judges and other justice system officials will need to know
all recommendations made regarding the proposed plan of treatment
based on the results of the assessment. If the assessment is
conducted in two stages, as discussed above, the justice system
officials must review the results of both. The results of the
first, more cursory stage will help a court decide whether to
place the defendant in a treatment program. The second part will
guide the choice of conditions the defendant must meet. Judges,
prosecutors, and the defendant's own lawyer need to know what
goals and objectives have been set for the treatment plan, how
they are to be measured, and when and how they will receive information
about the defendant's performance in treatment.
In designing a drug court program, planners must make difficult
decisions about the types of services that will be available
through the treatment program, and about where, when, by whom,
and for how long these services will be provided for the target
population. Because substance-abusing populations and treatment
resources that are available (or that can, realistically, be
developed) vary widely from jurisdiction to jurisdiction, each
is likely to develop its own approach. This section provides
general information on categories of care and treatment modalities
that are widely (although not universally) available. It is
up to the program planners in each jurisdiction to decide what
categories of care and treatment modalities and services make
sense for the target population.
Substance abuse treatment services range across a continuum
that comprises three major categories of care: pretreatment
services (education/prevention); outpatient treatment; and inpatient
treatment (including residential treatment).
Pretreatment services include primary prevention (for those
who have not yet abused alcohol and other drugs) and early intervention
(for people who have begun to abuse alcohol and other drugs and
are considered to be at high risk for developing problems related
to use). Pretreatment services are not part of primary
treatment. They typically consist of psychoeducational services
designed to increase individuals' awareness of the dangers of
substance abuse.
This is the most common form of substance abuse treatment,
including both 1/2- to 1-hour individual sessions and intensive
day treatment centers. Outpatient treatment has advantages over
inpatient or residential treatment (for clients who are not in
need of acute care) in that the client can maintain or seek employment,
remain with family, and maintain contact in the community during
the treatment process. Types of outpatient treatment include
Non-intensive outpatient treatment
Intensive outpatient treatment
Opioid substitution therapy
Day treatment, partial hospitalization, or day reporting
centers.
This type of care can be provided in a hospital or medical
facility (for those with the most acute treatment needs), or
in a wide range of other types of therapeutic residential settings,
such as apartments, dormitories, and supported housing. The
residential programs may be secure or non-secure facilities,
and the length of stay and costs of treatment can vary considerably.
Types of inpatient treatment programs include the following:
Length of treatment is an issue closely related to the category
of care. To a significant extent, the length of treatment offered
by many providers has been shaped by insurance companies' policies
concerning payment for treatment services. For example, insurance
companies have commonly used a standard of 28 days for reimbursable
residential treatment, and many private treatment providers have
designed 28-day residential programs. The needs of the pretrial
defendant target population, however, will seldom fit the 28-day
model. Recent research has verified that clients in a criminal
lifestyle that includes substance abuse need a minimum
90-day treatment intervention to change their behavior. Most
treatment drug courts provide for at least six months of supervision
and treatment services. Justice system officials and substance
treatment providers together should develop cost-effective programs
that can meet the needs (and limitations) of the target population,
the justice system, and the treatment community.
Detoxification is the process through which a person
who is physically dependent on alcohol, illegal drugs, prescription
medications, or a combination of these drugs undergoes medically
supervised withdrawal from the drug or drugs of dependence.
Detoxification is an important part of the treatment process,
because it is difficult to properly assess an individual or provide
treatment for the underlying substance abuse if the individual
is inebriated or in the early stages of withdrawal. In severe
cases of dependency or withdrawal, the individual may be unresponsive
to questions. Detoxification stabilizes chemically dependent
defendants and allows them to move on to the next step in their
recovery.
Withdrawal symptoms can range from mild discomfort to acute,
even life-threatening symptoms such as convulsions, hallucinations,
suicidal ideation, and severe depression. Medication can reduce
some of the discomforts of withdrawal and minimize medical complications.
Blood pressure monitoring and medical supervision may be required,
depending on the drugs used by the defendant and the clinical
symptoms of withdrawal. TIP 19, Detoxification from Alcohol
and Other Drugs (CSAT, 1995), provides
guidelines for safe, medically managed withdrawal.
Some jurisdictions, such as Dade County, Florida, have used
existing services such as hospitals while building their own
detoxification services for outpatient use. In addition, jail
detoxification and treatment programs have been used to treat
more difficult cases. Once the unique needs of substance-abusing
offenders are identified, many programs have tailored their detoxification
procedures to fit client needs.
Many communities have detoxification centers, either in a
criminal justice or social services environment, that are supervised
by a nurse and have a physician on call. Some hospitals, both
public and private, have detoxification units that range in duration
and intensity from short-term to long-term programs.
From a program design standpoint, there are several key questions
that must be addressed with respect to detoxification:
What agency or agencies will provide detoxification
services for arrested defendants? Are different approaches and
facilities needed depending on (a) security/custody needs with
respect to the defendant; and/or (b) the level of substance abuse
and probable severity of the withdrawal?
How can screening procedures be used to help identify the
detoxification needs of defendants?
How and when will defendants needing detoxification services
be transported to the appropriate detoxification facility?
What specific detoxification services will be provided?
By whom? For what period of time and at what cost?
In addition to traditional withdrawal methods, acupuncture,
an approach taken from Eastern medicine, is now being used
as an adjunct to assist in the detoxification process in some
jurisdictions. Several research studies have indicated that
acupuncture can be effective in reducing cravings and in ameliorating
withdrawal symptoms. The first court-linked program to extensively
use acupuncture was in Miami, Florida. Acupuncture is now an
integral part of court programs in a number of U.S. jurisdictions.
Before introducing acupuncture as part of a drug court program,
it is important to coordinate efforts with public health officials
to ensure that certification requirements can be met. In California,
acupuncturists are required to obtain the equivalent of a 4-year
medical degree. Acupuncture is offered as an adjunct to treatment
in many substance abuse treatment programs. Although full-body
acupuncture requires a facility that has beds and changing rooms,
it is possible to use much simpler (and less expensive) clinic
style methods. Current use of acupuncture to help with detoxification
generally involves a five-point auricular (ear) application.
This procedure can be applied by trained technicians to clients
who are sitting in chairs. This procedure is less expensive
than full-body acupuncture, and a State's medical authority may
certify it for use in treatment programs.
It should be noted that some substance abuse treatment professionals
object to acupuncture because they see it as a hindrance to treatment.
Some believe that acupuncture replaces the "needle ritual" that
is part of some drug users' lives. Others say that the calming
effect of acupuncture can undermine other treatment, which sometimes
requires confrontational approaches.
Planners may also want to consider detoxification approaches
that are culture-specific. For example, Native Americans use
sweat lodges for a variety of ritualistic and social purposes.
Assignment to a sweat lodge may be appropriate action to take
for Native Americans who do not exhibit life-threatening symptoms,
provided they meet other criteria of program eligibility. Latinos
and Hispanics may also use herbalists and "curanderos" who treat
withdrawal symptoms with traditional remedies. Although the
efficacy of such culturally based methods of detoxification is
not yet fully documented by researchers, the psychological and
social benefits to the individual who believes in these traditions
may be considerable.
Most treatment providers offer a range of treatment services.
It is important to remember that not all programs will provide
all services and that the level and focus of services provided
may vary widely from program to program. However, services generally
include
Evaluation and assessments: medical, psychiatric,
and substance use assessments
Treatment planning: medical, psychiatric, and addiction
treatment planning
Counseling/therapy: group therapy, individual counseling,
family therapy
Medical assessment and treatment, including attention
to HIV/AIDS, hepatitis, TB, and STDs
HIV/AIDS education, testing, and counseling
Comprehensive pregnancy care: prenatal care, parenting
classes, childbirth classes
Mental health services, including medications when
indicated
Education about substance abuse: lectures, interactive
groups, videos, reading assignments, journal and writing assignments
Self-help education and support, including Alcoholics
Anonymous (AA) and Narcotics Anonymous (NA)
Social and other support services for the offender
and family members
Relapse prevention services
Substance abuse treatment services to family members
and significant others
Acupuncture and other nontraditional detoxification
and healing techniques
Services for special populations, such as violent
offenders, incest survivors, incest perpetrators, and those with
dual disorders.
In addition, the treatment provider usually tries to link
the client with a variety of ancillary services to address other
problems. These may include
Education, including basic reading and math skills
Job training and counseling
Housing
Child care
Nutrition assistance.
Treatment providers increasingly note that many clients require
"habilitation," not simply "rehabilitation." In other words,
some addicted persons have not lost functional capacities and
skills as a result of their addiction but have, in fact, never
acquired them. Many persons, for example, have not acquired
the capacity to control impulses or to distinguish between emotional
states. Some lack the skills to sustain day-to-day relationships
with others, or suffer from Attention Deficit Disorder. The
fact that more and more clients suffer from a lack of basic capabilities
and skills makes the treatment of the underlying addiction more
difficult.
Components of aftercare in treatment programs typically include
Random drug testing
Self-help groups (AA, NA)
Acupuncture (in some jurisdictions)
Group counseling
Individual counseling
Employment
Education
Mentoring
Strengthening family and community ties.
Aftercare is a critical component of treatment. Even when
an individual has completed a treatment program satisfactorily,
the danger of relapse remains. This is especially true when
the client returns to the community after time in a residential
program and is confronted by the conditions (including friends),
that promoted substance abuse before treatment. In designing
a drug court program, it is important to devise aftercare services
in which the client has routine access to self-help groups and
counseling sessions.
The last decade has seen much greater attention paid to the
role of each client's culture in the treatment process. Because
treatment is so intense and stressful, it is preferable for clients
to obtain services not only in their native language but sensitive
to their culture's patterns of beliefs, feelings, and behaviors.
For example, Western cultures tend to stress individualism and
self-control, and clients from more family-centered cultures
respond better to a family-oriented approach to treatment. In
traditional Western cultures, introspective discussion of one's
personality and behavior in a group setting is not uncommon,
but such self-disclosure is utterly foreign in some other cultures.
The best treatment programs take their clients' cultural backgrounds
into account.
Both substance abuse treatment and criminal justice professionals
often fail to appreciate the great diversity among the immigrant
groups in the United States. For example, Spanish-speaking cultures
are treated as one "Hispanic" entity, even though Mexican, Puerto
Rican, Cuban, and Central American cultures differ significantly
from one another. It is very important for criminal justice-based
treatment programs to be sensitive to these and other areas of
diversity, and to make certain that treatment resources include
programs for the principal ethnic and racial minorities in their
jurisdictions.
There is a discussion in Chapter 3 of issues
regarding the target population and possible points of intervention.
During the program design stage, initial plans concerning these
issues must be translated into decisions about the types of defendants
who will be eligible for the program, what information and advice
these defendants will be given concerning possible participation
in the program, and when and how participants will be selected.
The issues of eligibility and suitability relate directly
to the screening function discussed at the start of this chapter,
and, more broadly, to the overall goals of the program. In the
design stage, the program goals, together with the planners'
knowledge about treatment resources that are available or can
be developed, should help shape the criteria for admission to
the program.
In general, jurisdictions that have initiated treatment programs
for pretrial defendants begin by targeting those regarded as
relatively low-risk offenders in terms of public safety considerations.
For example, defendants with a history of committing violent
offenses are often not eligible for a treatment program even
if their current charge is a nonviolent one (such as possession
of an illicit drug). In some places, as programs have gained
experience and developed credibility with the public and with
justice system officials, the eligibility criteria have been
expanded to include a broader range of defendants.
Examples of eligibility criteria used by drug court programs
include
Current charge of purchase or possession of a small
quantity of illegal drugs; may also include possession with
intent to sell or distribute
Current charge of another nonviolent offense (for
example; theft, forgery, passing worthless checks, prostitution,
or burglary), committed while under the influence of drugs or
alcohol
Current charge of operating a motor vehicle while intoxicated or under the influence of drugs or alcohol
History of substance abuse problems, including recent
abuse
Criminal history that does not include conviction
of a felony crime or violence
Willingness to participate in a treatment program,
having been informed of the conditions of participation.
Suitability criteria are more difficult to apply. It is clear
that there are some situations in which, although technically
meeting the eligibility criteria, the defendant is unlikely to
benefit from the program, may disrupt program activities, or
may need medical attention before being considered for admission
to the program. Examples of categories of defendants often not
accepted into a program include drug traffickers and dealers;
defendants who have severe psychological problems (e.g., persons
who may be receiving psychiatric medication but are not stabilized
on their medication); and defendants with medical conditions
that require immediate attention.
Establishing clear criteria for admission to the program is
a critical first step. With these criteria in place, the design
team can develop additional procedures for identifying defendants
who are both eligible and suitable for admission to the program.
Because jurisdictions organize post-arrest case processing in
different ways and have differing legal requirements concerning
issues such as speedy trial rights, appointment or assignment
of counsel, and use of deferred prosecution or deferred judgment,
there is no single sequence of events that is appropriate for
every jurisdiction. However, the design team in any jurisdiction
should be prepared to address the following questions:
Who (what agency or agencies and what individuals)
will conduct the initial screening for criminal justice charges
and prior history, substance abuse, and infectious disease problems?
Where will this be done? What access will the screeners have
to criminal history information?
Who will be responsible for informing the defendant
about the possibility of participating in a treatment program?
When will this be done? What information will be provided to
the defendant at this time?
At what stage will the defendant have the opportunity
to consult with defense counsel concerning the possibility
of participating in the treatment program? What information
will the defendant and defense counsel have at that point, concerning
the current charges against the defendant and the duration and
conditions of participation in the program?
What are the potential benefits to the defendant from
"successful" participation in the program (e.g., dismissal of
charges; vacating of plea or conviction)?
What rights, if any, will the defendant have to waive
or relinquish in order to participate in the program? Will
a plea of guilty, or agreement to stipulated facts, be required
as a condition of participation?
How much time will the defendant have to consider the
possibility of participating in the program? Regardless
of the defendant's initial decision, will there be an opportunity
for reconsideration?
How will the court, the prosecutor, the defense counsel
and the defendant know if there is an open "slot" in a treatment
program appropriate for the defendant?
What role does the treatment provider have in the initial
decision to admit the defendant to the program? How will
this vary if the program uses multiple providers?
What role does the prosecutor have in the initial decision concerning admission of the defendant to the program?
How soon after the initial arrest does the judge consider
the defendant's admission to the program? What information
and recommendations will the judge have at that point? From
what sources?
What is the range of options available to the judge
concerning admission of the defendant to the treatment program
and establishment of conditions for participating in the program?
What conditions will usually be imposed and what factors control
their imposition? To what extent, and how, will urine testing
be used as a condition of program participation?
When will treatment begin once a defendant is admitted
to the treatment program?
Every jurisdiction that has established treatment programs
linked to pretrial case processing has answered these questions
in its own way.
One of the hallmarks of the newer drug court programs is a
strong emphasis on active judicial oversight of the defendant's
performance in the treatment program.
The judge will generally require the defendant to appear at
regularly scheduled status hearings, at which the defendant's
treatment progress is reviewed. While patterns vary from court
to court, the status hearings may be held as often as once a
week during the first month or so. As treatment progresses (and
especially if the defendant appears to be making satisfactory
progress), the frequency of the status hearings decreases, but
the court continues to monitor the defendant's performance.
At the status hearing, the judge reviews reports from the
case manager or treatment provider and possibly from other parties
that have a role in the treatment process. Topics covered at
the hearing ordinarily include
Substance use test results (e.g., urinalysis)
Report on defendant's attendance at treatment sessions
Report on defendant's attitude toward treatment, including
recognition of the substance abuse problem.
In addition to these substance abuse and treatment-specific
topics, the judge may also inquire about other aspects of the
defendant's life, including housing, work, family, and general
health. The judge can thereby develop rapport with the defendant
and support the defendant's efforts to overcome the substance
abuse problems.
One key aspect of judicial supervision of the defendant's
performance in treatment is the use of sanctions when a defendant
fails to comply with program conditions and rewards for continued
abstinence. The ways in which sanctions and rewards are used
varies considerably from jurisdiction to jurisdiction, but their
use reflects an orientation very different from the traditional
response of the court to substance-abusing offenders.
Traditionally, if a defendant was caught using alcohol or
drugs in violation of conditions of probation, his or her probation
was revoked. By contrast, programs that integrate substance
abuse treatment with pretrial case processing deal with renewed
use of alcohol or other drugs as part of the recovery process.
Most individuals with severe substance abuse problems have
few coping skills to help them deal with situations where they
are tempted to use alcohol or drugs. "Relapse" (sometimes
called "backsliding") is common. Indeed, many substance abusing
individuals relapse and return to treatment several times before
achieving abstinence from alcohol or drugs for any appreciable
duration. But the fact that relapse is common does not mean
that it is ignored. On the contrary, one of the functions of
the judge in an integrated program is to take appropriate action
to reinforce the treatment program.
A treatment report that presents evidence of relapse (for
example, a succession of positive urinalyses for drugs for a
drug-using defendant; failure to attend treatment sessions) is
a signal to the court that the treatment plan needs to be reviewed
and that some type of sanction is probably needed. Sometimes
a verbal admonition by the judge is all that is needed. At other
times, it may be necessary to increase the frequency of urine
testing and counseling sessions, or to schedule more frequent
status review hearings. If these approaches don't work, it may
be appropriate to place the defendant in jail or a community
correction facility, perhaps increasing the duration of imprisonment
at each violation.
Jurisdictions vary considerably in the policies they follow
in responding to noncompliance with program conditions. The
main point is to ensure that there are consequences for noncompliance,
and that they are imposed fairly and consistently.
When defendants perform well in treatment, there should be
some recognition and reward for their progress. One obvious
reward is the dismissal or lessening of charges upon successful
completion of the treatment program. It also helps to acknowledge
progress along the way -- even modest progress. For example, a
succession of negative urinalyses for drugs and regular attendance
at treatment sessions can be publicly acknowledged by the court
at a status review hearing. Such progress can also be rewarded
by reducing the frequency of status hearings or the intensity
of the treatment program. Some programs conduct a graduation
ceremony and award certificates when defendants successfully
complete treatment.
Staffing for an integrated program requires teamwork across
agencies and institutions that generally have little history
of working collaboratively. As noted earlier, this new team
needs to develop a plan that ensures client accountability through
a balance of supervision and graduated sanctions and treatment
interventions. Those elements should be seen as mutually reinforcing.
For justice system members of the integrated program team,
involvement in the program means shifting their primary focus
from the guilt or innocence of the defendant to effective interventions
for defendants admitted to the program.
Optimally, members of the program team for the pilot or startup
phase of the program will have had some involvement in the initial
planning and in the detailed design of the program. Planning
and designing the program will give team members a basic core
of knowledge about substance abuse treatment and will familiarize
them with the approaches and techniques used in other jurisdictions.
While the composition of the teams and the precise roles and
responsibilities of each team member will vary, it is possible
to identify some important court-based roles and functions that
will be common to most integrated programs:
The judge will play a central role in the program. Generally,
the judge will explain the defendant's legal rights and options
and the program requirements at the defendant's first court appearance
and right before admission to the program. The judge will also
review treatment progress reports and discuss progress directly
with the defendant at status hearings.
The prosecutor will generally ensure that program participants
meet the established admissions criteria; will review treatment
progress reports and ask the judge to impose sanctions if the
defendant fails to comply with program requirements; and may
seek to remove from the program participants whose treatment
reports show no progress or who are arrested again for some kinds
of criminal conduct.
The defense attorney will review the charges against the defendant
as well as any information available from police reports or other
documents disclosed by the prosecutor; will advise defendants
about their constitutional rights (e.g., right to counsel, right
to speedy trial) and practical options, including participation
in the treatment program; will explain how various treatment
program outcomes will affect the disposition of the case; and,
if a defendant opts to participate in the program, will encourage
and support the defendant's participation and compliance with
program conditions.
A screening officer, who may be a pretrial services officer,
TASC program coordinator, a member of the jail administrator's
staff, or the incumbent of a newly created position, will be
expected to review the list of defendants arrested each day,
and will screen each case for program eligibility based on criminal
justice criteria such as current charges and prior record. This
individual may also conduct screening for substance abuse problems
and infectious diseases and may supervise defendants released
from custody for compliance with program conditions, including
periodic urine testing.
The court clerk or court coordinator will help schedule status
hearings and other court appearances; organize and prepare files
for cases on each day's calendar; help the judge review the status
of cases subject to judicial supervision; follow up on defendants
who fail to appear in court as scheduled; and stay in regular
communication with the judge, the treatment program liaison officer,
and others involved in program operations.
The assessment officer, typically an individual with master's-level
training in a discipline associated with substance abuse treatment,
or the equivalent in actual experience, will conduct the detailed
assessment of substance abuse problems described earlier in this
chapter and make recommendations concerning the appropriate category
of care and type of substance abuse treatment.
Case management is a term used by both the court and treatment/supervision
agencies. In the court, a case manager helps the judge manage
the court's pending caseload and daily calendars and acts as
liaison with representatives of agencies involved in the work
of the court (including treatment providers). In the treatment
community, the case manager is primarily the coordinator of a
team of service providers, including both treatment and ancillary
services such as housing, medical care, nutrition, literacy training
and job placement. In some jurisdictions, the latter function
is performed by the treatment program liaison officer.
This person will help explain treatment program operations
to defendants who may participate in the program; will ensure
that treatment progress reports are provided to the judge and
to the prosecutor and defense lawyer in advance of status review
hearings; will provide information on available treatment slots;
and will help arrange for transportation of the defendant to
the treatment program.
This listing of staff roles is to some extent oversimplified.
In actual practice there may be some revision or consolidation
of roles and perhaps some additional functions. The titles and
responsibilities of individuals participating in the program
team, as well as the organizations and agencies with which they
are affiliated, will vary from community to community.
Moreover, while there are strong arguments for beginning program
operations with a relatively small and cohesive interdisciplinary
team, it is important to remember that many other persons may
become involved in program operations at an early date.
In a large multi-judge court, for example, it is possible
that there may be more than one judge (and more than one courtroom
team) involved in the integrated program. Further, it is likely
that there will be some turnover in the judges and staff assigned
to the program team. Optimally, the initial personnel will hold
their posts long enough to establish the roles of all of the
team members and regular mechanisms for communication and exchange
of ideas.
Staffing for an organization that provides substance abuse
treatment integrated with pretrial case processing will vary
depending on the volume of cases, the categories of care provided,
the components of the treatment program, and the ways in which
the treatment program is linked to other social services in the
community. The director or chief executive officer of any organization
that provides treatment services integrated with pretrial case
processing should be regarded as a member of the program team.
So, too, should the counselors, case managers, and other treatment
professionals who will be working with pre-trial professionals.
These treatment community professionals need to understand the
operation and expectations of the justice system, just as justice
system professionals need to understand substance abuse treatment.
Information, about individual defendants and about treatment
programs, is essential for the effective management of both individual
cases and the overall drug court program.
On an individual case basis, information about the defendant
is needed to make initial screening decisions, to do a detailed
assessment of the defendant's treatment needs, and, if the defendant
is admitted into the treatment program, to monitor progress in
treatment, make revisions in the nature or intensity of treatment
provided, and impose sanctions or reward progress when appropriate.
This information is needed by the court, the treatment provider,
and sometimes by the prosecutor and defense lawyer. Signed waivers
and exchange of information are critical elements of the drug
court operation. Some information, particularly information
about the defendant's performance in treatment, may not be readily
accessible unless carefully drafted waivers of confidentiality
and interagency agreements governing the exchange of information
have been adopted and are used.
This is an area in which modern technology holds great potential
for far more rapid and comprehensive exchange of information
between treatment system and justice system agencies than would
have been possible in earlier years. With automated databases
in the courts and in many treatment agencies, and with the availability
of electronic communications mechanisms such as e-mail and faxes,
the transmission of information relevant to case monitoring and
decision-making can be almost instantaneous. Some jurisdictions,
such as Denver and Washington, D.C., make very effective use
of online linkages between treatment providers and judges who
have computers on the bench. When a defendant appears in court
for a status hearing, for example, the judge can directly access
information about the defendant's recent urine test results,
attendance at treatment sessions, and compliance with other conditions
of program participation.
While many jurisdictions do not currently have such online
exchanges of information, it is essential for the design team
to develop mechanisms that will ensure the rapid and complete
exchange of information needed -while observing the laws and
regulations governing the confidentiality of information.
The categories of information needed by the justice system
and by treatment providers for decision-making about individual
cases are remarkably similar. They include
Identifiers and locators such as name, age,
sex, race/ethnicity, address, phone, fingerprint identification
number, and court case number
The current charges against the defendant and the
facts allegedly supporting the charges
The defendant's criminal record, particularly any
previous convictions for offenses involving violence
The defendant's community ties, including family situation,
housing, and employment
The defendant's prior record of appearing for scheduled
court dates
The defendant's past involvement with substance abuse
treatment
The nature and severity of the defendant's substance
abuse problems
The nature and severity of any medical or mental health
problems
If the defendant is admitted to the treatment program, up-to-date
information on court case status and performance in
treatment, including attendance at treatment sessions and
results of tests for use of drugs or alcohol.
Information about individual cases and defendants, in addition
to being essential for case-level decision-making, also serves
a second vital purpose: providing the building blocks for effective
overall program monitoring and evaluation.
Monitoring and evaluation are closely related concepts, but
they are not the same thing. Monitoring is an ongoing
or periodic observation of program operations. The main purpose
is to ensure that the program stays on course and that the operational
procedures are revised if necessary. In the case of a drug court
program, policymakers and program managers should monitor operations
using indicators of program performance. These might include,
for example,
Number of defendants screened for program eligibility
and for substance abuse problems and infectious diseases, and
the results of those screening activities
Number of substance abuse treatment assessments conducted and the results of those assessments
Number of persons admitted to the program
Number of persons rejected despite screening that
indicated eligibility, and the reasons for the rejection
Characteristics of defendants accepted or not accepted
into the program, by
Demographics (age, sex, family status, race/ethnicity, employment
status, and education)
Current charges
Criminal justice history
History of treatment
Medical needs (including detoxification)
Nature and severity of substance abuse problems
Results of drug tests.
Caseload status of persons in the treatment program,
including
Number of cases by length of time in treatment (0-30 days,
30-60 days, etc.)
Number of cases by completion of stages of the treatment
process.
Number of persons who complete treatment successfully
Number of persons terminated from the program, including
Reason(s) for termination
Length of time in the program.
Accomplishments of program participants in terms of
Sustained abstinence from alcohol and other drugs
Improved job skills
Improved literacy skills
Improved health
Improved life skills.
Having knowledge about these factors, and others selected
as key indicators of performance, should enable program managers
to accurately assess the program's effectiveness, and make good
decisions about operational procedures and resource allocation.
The data needed for program operations usually can be obtained
from information used for day-to-day operations and routinely
collected for each individual in the program. Although many
programs rely on outside evaluators to provide them with information
on these topics, it should not be necessary to do so. With careful
attention to the development of databases and computer software
report formats (perhaps supplemented by manual counting in some
instances), program managers can have such information monthly
or weekly. Maintaining and sharing such information and using
it to analyze program operations can make a significant difference
in the effectiveness of a program.
The data needed for program operations usually can be contained
from information used for day-to-day operations and routinely
collected for each individual in the program. Evaluation, discussed
in more detail in Chapter 6, also involves
periodic observation of operations, but the focus is primarily
on assessment of a program's effectiveness in achieving its original
goals. Evaluation should draw on the same information base that
enables policymakers and program managers to monitor operations.
Feedback from evaluators, who are typically outside the day-to-day
operations of a program, can be helpful in supplementing what
the policymakers and managers know from monitoring program operations.
However, if the policymakers and managers are doing a good job
of monitoring, evaluation reports should seldom contain surprises.
Close attention to information needs, for individual case
decision-making in both the justice system and the treatment
community, for monitoring, and for evaluation, should be a part
of the design stage for every program. It will be a critically
important element of program operations.
When the design issues discussed in this chapter have been
resolved, everyone involved in development of the program will
know much more about key issues and operational details than
they did when the policy development phase ended and design work
began. It may be necessary to revise the Memorandum of Understanding
to reflect any major changes.
The next stage in program development is project startup,
followed by full-scale implementation, both discussed in Chapter 5. No matter how good the program design,
the process of startup and full-scale implementation will almost
certainly raise a number of unanticipated problems, requiring
further revisions of the MOU at later stages.
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