Continuity of Offender Treatment for Substance Use Disorders From Institution to Community
Treatment Improvement Protocol (TIP) Series 30

Jails

Several differences between prisons and jails affect the way treatment services and transition to the community are delivered. The most significant is length of incarceration. Because jails are used as pretrial facilities for pending court actions, it is often unknown how long an offender will be held, making treatment planning difficult for many jailed offenders. The policy in some States is to provide substance use disorder treatment if the offender is sentenced to jail for 60 days or more.

It is difficult to maintain continuity of treatment in a jail setting, because offenders move in and out of court. Incarceration often creates a crisis that ripples throughout an offender's life, affecting family, legal, and other matters. Children may be placed outside the home, and offenders may be in the process of detoxification. Because jail experiences can cause instability on so many fronts, social service delivery and crisis management are especially important.

The Consensus Panel recommends that treatment be provided if a substance-using offender is scheduled for confinement in jail for a period of time sufficient to provide adequate treatment for the offenders' needs. Inmates with shorter sentences can be placed in alcohol and drug education or other treatment readiness programming. Results from a recent evaluation of the effectiveness of a jail-based treatment program suggested that optimal treatment length is a period of 3 to 5 months followed by immediate placement in a community treatment program (Swartz et al., 1996).

Despite the problems, treatment in jails has some advantages, especially for transition work. The Cook County Jail Day Reporting Center, for example, trains offenders in life skills. More than a dozen social service providers in the community staff the reporting center and conduct trainings on rites of passage, violence prevention, parenting, and relationships. This program also has a training program for offenders who are drug dealers but not drug users.

Jailed offenders often have opportunities to receive substance use disorder assessment and treatment planning from community providers who come into the jail. Assessment or treatment planning that prepares the inmate for more structured treatment on the outside has the benefit of priming the inmate for more intensive treatment in a controlled environment that provides for public safety. Treatment units in jails also have less infractions and violence than other units in the institution.

Furthermore, the sentencing decision may be affected if a local treatment provider involved in the pretrial or presentence phase determines that the offender has demonstrated a willingness to participate in the treatment process and develops a treatment plan. Judges may even consider treatment as an alternative to incarceration. This option provides a strong motivation for many offenders.

A number of studies have shown that treatment effects on recidivism do not appear before about 90 days of treatment, and that treatment effects improve with time in treatment (Hubbard et al., 1989; Simpson, 1981, 1984). Time in treatment, whether in the institution or in the community, is a critical factor. Because jail sentences tend to be short, good jail-to-community continuity of treatment is essential for a longer singular treatment episode. Thus, the Consensus Panel recommends that the shorter the jail program, the more obligation the program has to ensure continuity of service. Even inmates leaving jail without a community sentence should receive a community treatment referral. Likewise, if the offender is sentenced to prison, a treatment plan should follow the offender to the designated correctional institution. If funding is limited, local Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings can be supported in the jail several nights a week. Those incarcerated hear "leads" from previous offenders, find sponsors and mentors, and become less resistant to community-based treatment.

Prisons

In contrast to jails, prisons house offenders whose sentences are generally longer than 1 year. Since offenders will be in prison for a substantial period of time, many prison-based treatment programs are able to provide extended treatment. Research demonstrates that longer treatment length can be associated with positive treatment outcomes including reductions in substance use, substance use severity, substance-related problems, predatory illegal acts, and increases in posttreatment employment and earnings (De Leon, 1984b; Gerstein et al., 1994; Hubbard et al., 1989; Simpson, 1981, 1984; Walker et al., 1983; Wexler et al., 1992).

Because they work with longer term offenders, prison treatment programs can conduct substance use disorder treatment well past detoxification or even long-term withdrawal -- while community programs must often address these issues while trying to rehabilitate. In prison, assessments can be more thorough, and there is time for reassessment and program adjustment to meet individual needs. The extended time frame also allows for practicing new life skills, as well as early and complete discharge planning. Basic education and mentorship programs often augment treatment in prison as well.

There are also disadvantages to prison treatment as it relates to continuity. The primary problem is "institutionalization." Learning to live in, and accommodating to, an institutional setting may make it more difficult for the client to readjust to community living. It is often difficult to maintain positive family involvement during long incarcerations. Also, while jails are located in the community, prisons are often geographically remote from the inmate's home or postrelease community.

In some jurisdictions, moving inmates from institution to institution because of limited bed capacity can be disruptive to programs. Some programs have agreements with institutions that if the risk status of an inmate in a treatment program changes (e.g., due to a disciplinary report), the offender can stay and continue treatment.

Boot Camp Programs

Boot camps, also known as shock incarceration programs, are based on a military model, and usually compared to basic military training. Boot camps are generally secure facilities characterized by a barracks-type living arrangement and significant physical exercise and discipline. One intent of military drills is for boot camp graduates to develop the self-discipline and pride to avoid future substance use. This is the theoretical underpinning of the boot camp discipline-training approach. The boot camp population generally includes

• Youth offenders
• First-time or early offenders, without a pattern of violence (i.e., offenders who have committed crimes against property or drug offenses, rather than crimes against persons)
• Probation violators (may be technical violations or new offenses)

Unfortunately, research indicates that most early boot camps fell short of their goals to reduce recidivism (Mackenzie et al., 1993). Several studies from 1990 to 1994 show that impact and recidivism were not significantly lower among prison-bound offenders sent instead to boot camps. The studies also indicate that treatment interventions and aftercare followup are important factors in actually reducing offenders' propensity to commit crime once released from boot camps (MacKenzie, 1990, 1993a, 1993b; MacKenzie and Piquero, 1994; Parent, 1993).

The extent of substance use disorder assessments and programming varies from boot camp to boot camp, but many programs have recently developed more intensive programming, including substance use disorder treatment. The Lakeview program in New York (see box) has been a model for many of these program-oriented boot camps.

In recent years, many boot camps have evolved away from punishment and military-style behavior change toward a greater emphasis on (re)habilitation. Surveys of boot camps indicate that apart from physical training, half of the program time is focused on substance use disorder treatment, education, and vocational skills (MacKenzie, 1993a).

Youth Detention Facilities

Youth detention facilities provide temporary care of juvenile offenders (or juveniles alleged to be delinquent) who require secure, physically restrictive custody pending other action in the juvenile justice system. Youth detention can take place pre- or postadjudication, and facilities are usually under local jurisdiction. Offenders are generally detained for relatively short periods of time with the goal of determining their needs and quickly moving them back into the community or into a less restrictive setting. Often, disposition of an offense will include a term of probation with a variety of conditions, including substance use disorder treatment.

Youth detention facilities differ from youth correctional facilities, which are usually under the jurisdiction of the State. Generally, correctional facilities have a higher level of security, offenders have longer sentences, and the facilities are mandated to provide education and other rehabilitative services. Although this section focuses on youth detention facilities, many of the same transitional issues are applicable to youth correctional facilities.

For youthful offenders, the period of community supervision is generally longer than the term of detention. This is particularly true for the very young offender. For example, a 13-year-old may spend only several months in detention but may remain under the jurisdiction of the juvenile justice system until her 18th birthday. The authority to apply sanctions to youth until they reach the age of majority is one of the factors that distinguishes the youth from the adult justice system.

There are many other differences between the adult and juvenile justice systems, including basic goals. The goals of the adult system include deterrence (both individual and general), punishment, incapacitation, and rehabilitation. The juvenile justice system generally does not emphasize punishment -- although this is changing in response to public concerns about youth violence. As the juvenile offender has most of his life ahead of him, the intent of the juvenile justice system is to correct youthful behavior through rehabilitative means, even if those means are coercive. Rehabilitation efforts are often extensive. Legal sanctions and mandated participation in treatment may be imposed for those youths assessed with substance use disorder problems. The goal is to bring as much leverage as possible to the child and family in order to achieve successful outcomes.

The temporary duration of juvenile detention, the age of the clients, and the responsibility of the juvenile justice system to act in a parental capacity make the transition and treatment needs of juvenile offenders unique. Additionally, some juveniles are held as "status" offenders; that is, certain behaviors are legally forbidden only because they are juveniles, such as truancy or running away.

Juvenile justice system goals emphasize

• A balanced approach to juvenile court interventions
• Community protection
• Accountability
• Competency development
• Individualized assessment
• Due process protection for youth involved with the court
• Manageable caseloads
• Appropriate dispositions
• Involvement of the juvenile's family
• Community-based interventions
• Victim involvement
• Meeting the needs of youth from special populations

Identifying the Role of the Releasing Agency During Transition

Community programs should determine the degree to which the releasing institution has addressed the key components of a successful transition: assessment, case management planning, and identification of the community resources necessary to support adjustment in the community. The community program should ask:

• How does the releasing agency determine the offender's needs after release and the appropriate level of supervision?
• What kind of case management planning is conducted to respond to those needs?
• What documentation is available to describe the results of these efforts?
• Is information maintained on treatment summaries and recommendations, consent forms, and assessments of medical, family, psychosocial, and mental health status?
• Will the agency release the offender's records in a timely manner to the community supervision authority and community treatment provider?
• If the releasing agency addresses transitional planning, what are the components of the transition plan? What other agencies should participate in a transition team to plan case management and implement tasks during the transition period?
• To the extent that transition planning is not performed by the releasing agency, how can another agency or agencies address the delivery of community-based services?

The Consensus Panel makes the following recommendations regarding the goals for communication with the releasing agency:

• The community provider and the releasing agency should discuss the roles of each agency during the transition.
• Community programs should become familiar with the forms and legal requirements used by releasing agencies. They must also be aware of the restrictions placed on the offender returning to the community, and the ways in which these restrictions affect the treatment process.
• Whenever possible, community agencies and releasing agencies should collaborate in designing forms to record offender progress.

Building on the Treatment Provided in the Institution

The community provider must find out what kind of therapeutic interventions occurred in the institution and develop a plan for the community program to build on these interventions. Specifically, the community agency needs to determine whether there was

• A comprehensive substance use assessment
• A formal substance use disorder treatment program
• An educational program
• Vocational training

The range of possible approaches to treatment in the institution and the offender's response to them can vary greatly. One individual may be released from a boot camp in which he internalized a great deal of structure and is therefore very compliant. Another individual may have been incarcerated several times and may have "failed" in six or seven treatment programs. These past failures may make the offender more difficult to engage in treatment, and the community provider must be prepared for this.

If formal treatment took place, there must be a clear understanding of what it entailed and the best method for building on it. Information on the components of the program and its duration is necessary to determine appropriate followup services. For example, if a long-term treatment goal is to promote self-sufficiency, to what extent were these skills developed in the institutional setting?

There are also negative behaviors learned in institutional settings. Community agencies need to be aware of the offender's disciplinary issues, substance use within the institution, and the other, more subtle influences of institutional life that may result in offenders attempting to deceive or mislead treatment providers. Unless they ask about these issues, community agency personnel may not receive this information.

Community providers should be particularly prepared for two behaviors that offenders may learn in institutions, both of which can make treatment extremely problematic. First, offenders learn that showing tender feelings or weakness in an institution is very dangerous and places one at great risk of emotional and physical assault. Second, they often become "institutionalized"; that is, they become habituated to institutional norms and control -- from getting up in the morning until lights out at night. If an offender has been in an institution for a long time, it will be very difficult (and scary) for him to learn to take responsibility for his daily activities. These two behaviors reinforce each other in ways that can undermine treatment.

The most successful programs work on issues directly related to the factors that lead to criminality rather than on general life enhancement. Such issues are best addressed by methods that make use of reinforcement, graduated practice, modeling, and cognitive restructuring -- particularly with higher risk cases (Holt, 1998).

Training Counselors To Work With Offenders

It is important for community-based treatment providers to understand the emotional and social needs of their clients. Without this understanding, the offender and the treatment provider will not have shared expectations, goals, and objectives, and offenders in transition are not likely to become or remain engaged in treatment.

Community treatment providers working with offenders should receive education about the mores of the criminal subculture, the prison environment and structure, offenders with substance use disorders, and the criminal justice system in general. The Center for Substance Abuse Treatment (CSAT) and Virginia Commonwealth University have developed Criminal Justice-Substance Abuse Cross Training: Working Together for Change (Virginia Addiction Technology Transfer Center, 1996), which addresses such issues. This 15-module training manual provides instruction on the ways in which treatment and corrections systems can work together effectively. This curriculum was designed to be adaptable for different audiences and is available from Virginia Commonwealth University Addiction Technology Transfer Center. Similar training programs have been developed and implemented by the New York State Office of Alcoholism and Substance Abuse Services and the Oregon Office of Alcohol and Drug Abuse Programs. The training explains the criminal justice system to counselors, and helps them recognize and respond to offender clients' cognitive distortions that support both criminality and addictions.

Voluntary Versus Mandatory Treatment

Community programs must understand how substance use disorder treatment fits with the legal and supervision requirements on the offender. The provider must be sure that the client is aware of any mandatory requirements for treatment. While the offender may not agree with these requirements, he must be aware of them and understand them.

Even the client who wants to work with the treatment provider is often motivated by the desire to complete a specific supervision condition, rather than by a long-term rehabilitative goal. In an institutional setting, offenders may be motivated to enter treatment for incentives such as early parole or improving their security classification. For female offenders, one motivating factor might be the possibility of regaining custody of children. In some cases, treatment is offered as an alternative to incarceration or as a condition of release. At its best, the treatment process changes the negative attitudes and limited goals. As the client becomes engaged in the treatment process and sees the possibility of change, there is usually more investment in the process and an internalized motivation for self-improvement.

Even if the offender enters treatment merely to fulfill a condition of probation, this does not mean that treatment is of no value. In fact, studies indicate that coerced treatment is as effective as voluntary treatment, in part due to the fact that clients remain in treatment longer, and a longer length of stay is associated with reduced rates of relapse (Weinman, 1992; Young, 1995; Inciardi, 1996).