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

Housing

It is very difficult for a substance-using offender to make a successful transition to the community without housing that is safe, secure, and free of substances. Upon release, many offenders return to the environments that originally contributed to their drug problems and other criminal activities. Therefore, making sure the offender has suitable housing should be one of the transition team's top priorities. Ideally, substance use disorder treatment is integrated into the housing situation in residential treatment or a halfway house.

Because safe, secure, and drug-free housing is so important -- and often difficult to obtain -- a housing plan should be in place before release from incarceration. The offender, along with the transition team responsible for this service, should identify a living arrangement that meets his needs and then arrange a linkage with the entity providing housing. Local housing agencies can be brought into the team as partners in this effort. Working with publicly subsidized housing, such as Section 8 housing available through the Department of Housing and Urban Development (HUD), can be time-consuming and confusing.

Graduated levels of structured living environments are helpful in easing an offender toward independent living. Community treatment providers can operate supportive living arrangements for offenders engaged in outpatient care. These would be low-cost, substance-free housing environments with a level of peer supervision and support for recovery. Some options are residential treatment facilities, transition treatment centers (such as the Key-Crest program), halfway houses, parole restitution centers, sheltered living situations (such as Oxford House; see box above), and the offender's own home. Special populations, such as mentally impaired or juvenile offenders, may have available housing designed specifically for them.

Employment

Preparing an offender to seek and maintain employment is another key element of a transition plan. Employment serves several significant purposes for the offender, in addition to providing a source of income. Working augments self-esteem, provides the opportunity for socialization, demonstrates accountability for self, and is an essential step toward entering mainstream society.

There exist considerable obstacles to employment for substance-using offenders. Many lack job skills because they were unemployed or underemployed before incarceration. Offenders may also lack the social skills necessary to seek and hold jobs. Training programs conducted in prisons or jails can help offenders develop these skills and give them reasonable expectations of the types of jobs they may be considered for. It is also important that offenders develop coping skills that can assist them when they encounter negative attitudes in the community, such as the stigma associated with having been incarcerated. Disclosure of the need for substance use disorder treatment may also alienate some employers.

Planning for employment should begin well before release. While still incarcerated, offenders can benefit from job training and job readiness preparation, skills identification and assessment, role playing for future interviews and job situations, and reach-in programs that serve as quasi-internships or offer transferable pre-employment experience. Prior to release, case managers often develop a resource directory of employers that will hire offenders and talk with probation and parole officers about employment possibilities. There are often many available partners in the community ready to help with the employment component of transition.

Some correctional agencies conduct job fairs in which local businesses provide information on available positions in the community. Staff and volunteers conduct these job fairs for inmates who are about to be released. These events provide an opportunity for employers to visit the prison units and conduct practice interviews, assist with resume writing, and conduct job skills assessments. This has proven to be a "win-win" situation for employers and offenders. The offenders are prepared to seek jobs that may be available in the community and the employers fill their vacancies and network with other employers.

State and local entities have a large role in fostering job creation and placement. In Texas, Project RIO (Re-Integrating Offenders) is geared toward helping inmates make the transition back into the community. The Texas Department of Criminal Justice and the Texas Workforce Commission collaborate to provide job skills training and job referral/placement services to offenders prior to release. Often, Project RIO works with offenders to build on vocational skills to obtain employment after release. The Project maintains relationships with various job training programs and employers who are willing to hire offenders.

When an offender is offered a job, the case manager and/or community supervision officer should determine whether the job provides a supportive environment for recovery. If substances are available on the premises, the placement is obviously inappropriate. The new employer may be enlisted as a member of the community supervision team, serving as a point of support and accountability. Some employers will help a case manager monitor an offender for signs of relapse. Case managers and community supervision officers can help to coordinate the timing of service appointments so that there is no conflict with the demands of job programs and employers. It is critical that the offender satisfy both job requirements and treatment needs. For more information on employment issues, refer to the forthcoming TIP, Integrating Vocational Services With Substance Use Disorder Services (CSAT, in press).

Family

Families and significant others can have both positive and negative roles in offenders' lives. Some provide support for a successful transition to the community, while others may present barriers to recovery because of their own substance use (or other problems). Prior to release, it is important to know whether the offender's family environment will be a source of strength or an inducement to return to substance use and crime. Therefore, a prerelease assessment of the family environment should be conducted. This assessment should measure

• Whether other family members are using substances
• Whether there is domestic violence
• The level of support for sobriety
• Hopes regarding family reunification
• Current child care and child custody status
• The availability of family members in nurturing roles
• The family services already in place
• Areas of potential vulnerability

Sometimes it is difficult to enlist family members because they are unable or unwilling to participate in rehabilitation efforts. If the correctional facility is far from the inmate's home, it may be hard for family members to have regular contact. Paroled prisoners may not be able to cross State lines to see loved ones. In some cases, families "disown" an offender because of her criminal and substance-using behavior.

If, however, the offender's family wants to aid in the transition, the case manager should include it in prerelease sessions. Families then become an active part of the therapeutic process. Family members can benefit from support groups, such as Alanon, Narcanon, and Prison Families Anonymous, which provide peer support. Some jail and prison treatment programs provide groups for family members to help them identify relapse issues and to develop strategies to assist in the transition process.

Fostering communication among family members and probation officials and treatment personnel is beneficial as long as it does not violate confidentiality. The offender's family can receive ongoing information about ways to support, rather than undermine, sobriety and crime-free behavior. They can also be educated to become wise consumers and help in obtaining the best services for their family member. The family can also help enhance accountability, but enlisting relatives' help must be handled delicately. If a loving family member monitors for relapse and is willing to report the offender to authorities, the offender may feel he has nobody he can trust. In extreme cases, the family member might be in physical danger if the offender reacts with anger at being reported.

For women, family issues may be especially complex (see Chapter 6). As a result of incarceration, many women have had a change in family structure or relationship status. They may have been abandoned by men; if they have children, the children may have been placed in foster care or have bonded with another adult. The stress for the woman attempting to re-enter the family unit can be substantial.

The case manager can ensure that offenders with children have adequate parenting skills and access to appropriate programs. If there has been a change in custody during incarceration, the case manager may work with personnel in departments of child protective services to determine the best interests of all family members. Churches and private groups can be useful for general parenting support, and Parents Anonymous provides support for families in which there has been a history of neglect or abuse. When there is a child support obligation, the case manager can help find a means for facilitating prompt and full payment.

Peers

Peers can either inhibit or support the reintegration of an offender to the community. Many offenders have friends from their pre-incarceration days who are substance users and therefore represent a major threat to their sobriety. Because freedom from incarceration presents so many changes, offenders will naturally be drawn to the familiar, including old friends. It may be necessary to create an entirely new network of friends and to pursue new, substance-free, recreational pursuits. It is ideal to start contacts with mentors, role models, or sponsors prior to release. (Chapter 2 describes the roles of such individuals in the transition of the offender.)

Some States have laws that prohibit exoffenders and/or felons from associating with one another. These laws can have a negative effect on recovery by inhibiting supportive peer relationships after release.

Permanent sobriety often involves avoidance of people, places, and things that may trigger relapse. The case manager (or those providing case management functions) can guide an offender toward new contacts. Formal peer support groups are invaluable. A directory of peer groups and services can be maintained by the case manager, who should also identify whether support groups are open or closed to observers, their focus, and where they are located.

It is important to help inmates anticipate likely triggers for substance use on the outside so that they can avoid them. The "Opportunities to Succeed" program in Tampa, Florida, funded by the Center on Addiction and Substance Abuse (CASA) at Columbia University, is an example of an aftercare group providing treatment following release from jail. Jail alumni meet in weekly groups for 2 hours to review relapse prevention strategies. A case manager leads these groups, and family members are encouraged to participate. A similar program is WomenCare, Inc., a private not-for-profit mentoring program in New York City that recruits and trains volunteer mentors to help women released from prison adjust to life outside.

Transportation

To successfully reintegrate into the community, an offender must be able to get to work, to treatment meetings, and to appointments with parole officers, case managers, community service coordinators, and others. The case manager must ask an offender about transportation, because it may be a significant issue. For example, many offenders do not have a driver's license.

Although a lack of transportation may sometimes be used as an inappropriate excuse for noncompliance with treatment obligations, this is often a legitimate barrier, especially in rural areas. The case manager should coordinate any options available and advocate for policies ensuring that offenders are transported from correctional settings to community-based programs. If the offender is being released into residential treatment or a secure facility in the community, he will need transportation from the institution.

The transportation needs in rural and urban communities are very different. In remote areas, the case manager should be aware of programs that use satellite locations in churches and other public buildings. This may affect the decision about the location of nonresidential treatment. Transportation requirements can be met by innovative means: Reconditioned bicycles have been used in one area. Vans or car pools are another option. In more densely populated areas with mass transit, some programs have provided bus tokens.

Transportation problems are not limited to the postrelease period. As part of prerelease planning, reach-in efforts by family and peers may need coordination by the case manager if the institution is far from the offender's home. A program in New York provides transportation to visitors in 50 prisons in the State for a nominal fee. Since 1972, Operation Prison Gap has transported almost 2 million individuals to correctional facilities throughout the State. It was founded by a former inmate who was concerned about family members who had no means to visit their incarcerated loved ones. Originally a small volunteer organization, it grew into a successful privately owned business that meets a vital need for offenders and their families. Some States have implemented similar programs to address this need.

Education

Education is a building block for self-esteem and employability and is therefore of great importance in aiding sobriety. Research has shown that treatment outcomes improve when combined with education programs. However, low educational attainment is common among offender populations and even those who have a diploma may have poor reading and math skills. Offenders often exaggerate or distort their background and abilities, so achievement and literacy testing should be conducted inside the institution prior to release. Some offenders try to hide their lack of literacy or claim to have graduated from high school when they have not. Others have graduated from impoverished school systems and cannot read or do arithmetic. Offenders have higher rates of attention deficit disorder and other learning disabilities than the general population. One-fourth of children with conduct disorders and attention deficit/hyperactivity disorder (AD/HD) develop substance use disorders and become involved in crime (Harvard Medical School Health Publications, 1995). Many of these children grow up "self-medicating" their cognitive problems with substances, sometimes exacerbating their mental and physical health problems. A proper assessment can help identify and remedy educational deficits and uncover special needs, such as dyslexia, AD/HD, or other learning problems. Incarceration is an optimal time for these educational opportunities.

Offenders can be helped to develop not only basic skills but also a realistic plan for furthering their education. They can be provided with continuing education opportunities and financial aid information. If an offender is ready for college, grant and scholarship information is important. Some jurisdictions charge a fee to give the GED; a case manager can help the client resolve this and other barriers to continued education efforts (such as poor time management). After release, the offender must avoid creating time conflicts among her various obligations, such as job training or securing employment, treatment, and other services. In some cases, education is mandatory, as some judges require offenders to take GED classes before community supervision ends.

A number of individuals and entities may have roles in educating offenders. The Board of Education in the locality for each prison or jail has responsibility for providing education leading to a high school equivalency degree. Literacy volunteers, mentors from the community or tutors (who may be other inmates) can also be helpful. Many colleges and technical schools hold programs in correctional facilities.

Primary Health Care

The substance-using offender population suffers more health problems than the general public. The sobriety achieved in an incarcerated setting may reveal medical conditions that were formerly masked, so that incarceration results in diagnosis and treatment. Some commonly found health problems are

• Communicable disease, including HIV, STDs, tuberculosis, and hepatitis
• Chronic illness, including AIDS, diabetes, congestive heart failure, and asthma
• Mental illness
• Suicidal ideation
• Dental problems
• Organic deficits

A comprehensive health assessment is vital to the offender's well being and thus to a successful transition. If medical problems have been identified, the case manager should ensure continuity of medical care. In many locations, an exoffender is given a 10-15 day supply of prescription medications upon release. The case manager should notify any recipient agency of the offenders' medication needs. As discussed in Chapter 5, the systems working with the offender need complete transfer of medical records. Confidentiality issues must be addressed so that they do not interfere with the receipt of records by the entities that need them. In some situations, the case manager may have to deal with health-related obstacles to treatment. Contagious diseases, for example, may preclude treatment participation.

Once an offender graduates to community supervision, correctional system responsibility for health care usually ceases. Various payment and eligibility options for health care may be available, and the case manager should investigate these options prior to release. Offenders will often need help applying for social security benefits, Medicaid, veterans' entitlements, and any other benefits for which they are eligible. Applications for benefits can be filled out while the offender is still incarcerated; advocacy groups may be of help in this regard. Health education is a key service for special and general populations alike. This education should be conducted both during incarceration and after release.

Substance use disorder treatment should be holistic, taking into account all aspects of a client's life. Nowhere is this more important than with offenders undergoing the drastic change of release from incarceration. This population will confront more triggers for use relapse than most people as they try to learn how to live "on the outside" with the stigma of being criminals. Without such basic supports as housing, employment, and health care, offenders have reduced chances of becoming substance-free.

Quality, comprehensive health services in the correctional setting form the foundation upon which to build solid specialized treatment programs. Voluntary accreditation programs such as that offered by the National Commission on Correctional Health Care (NCCHC) provide standards for health services that help ensure that necessary basic health services are being provided to the facility's population.

A comprehensive health and mental health screen is vital to the offender's well being and thus to a successful transition. In correctional health care, a screening is customarily done upon admission. The people administering the intake screening should be properly trained in a manner approved by the institution's health authority. The screening should be followed up by a complete physical exam performed by a State-licensed clinician. The NCCHC writes health system standards for jails, prisons, and juvenile confinement facilities. They require that intake screenings be followed up with comprehensive physical exams within 7 days in prisons or 14 days in jails.

Recommendations for Coordinating Ancillary Community Services

• Various service providers can be convened in a community coalition to promote access to offenders as they make the transition into the community. This kind of effort builds linkages among different service systems and facilitates the job of the case manager or boundary spanner.
• Face-to-face contact is important so that the members of the team can explain what services they have to offer and can exchange phone numbers and specific information about their programs (such as the name of the contact person and how many slots are in the program).
• Networks can be created that link service providers and the legal sanction agency (see the text box on the Criminal Justice Treatment Network Demonstration Program in Chapter 3).
• Direct contracts can be made by the corrections system with community organizations providing formal services, such as residential and outpatient treatment services, job training, and life skills training.
• Increasingly, treatment providers are purchasing housing for offenders re-entering the community. In addition to providing the obvious need for shelter, it provides a positive social setting because the other tenants, also in transition, can give support to one another.
• Conditions of probation and parole can be modified where possible to require participation in ancillary services (e.g. parenting classes, substance use disorder treatment).