It is well documented that the most effective substance use disorder treatment is multifaceted and addresses many aspects of the substance user's life. This is particularly true for criminal justice populations, yet treatment providers generally do not match offenders with substance use disorders to services tailored to their needs. Effective care for those with mental and physical health problems, for example, must incorporate the care of these illnesses into the plan for treatment of substance use disorders and criminality. Assessment and treatment efforts must also acknowledge and incorporate the offenders' differences in culture, gender, age, and type of criminal offense.
People with mental and physical health problems constitute a major category of special needs populations. Society's failure to provide appropriate options for them contributes to disproportionately high numbers of these individuals who eventually find themselves under criminal justice supervision -- and many of these offenders, particularly the mentally ill, cycle through the criminal justice and social services systems repeatedly because their problems are not fully addressed in any system. For example, once individuals with mental illness are incarcerated, short-term goals of controlling undesirable behavior and a reliance on medication often take precedence over more comprehensive approaches to treatment.
Upon release, offenders with multiple problems suffer from an additional stigma and may be denied services because community providers lack training to deal with their problems. For example, providers who do not understand the issues for those with mental illness or mental retardation may believe that these individuals cannot benefit from treatment and are dangerous. Part of the case manager's job is to add to the transition team those specialists who can correct such misinformation.
However a population is defined (e.g., by a health problem or cultural background), it is important to know the substances of choice, types of crime, and other life patterns. Elderly people, for example, abuse prescription drugs and alcohol, but rarely use illicit drugs. People with mental retardation are often arrested for nuisance offenses and may be manipulated into criminal activities. Women's substance use is often woven into their intimate relationships; many are incarcerated for possession of a drug that their significant others are selling. These substance use patterns have significant implications for treatment.
Cultural sensitivity and cultural competency, important in all treatment, are particularly essential with offender populations, because minorities are notoriously overrepresented in incarcerated settings. For example, 40.5 percent of the prison population is African-American (Department of Justice, 1998), even though African Americans make up only 12.7 percent of the general U.S. population according to September 1998 census data (U.S. Census Bureau, 1998). For some offenders, such as those of African-American and Latino heritage, the family and extended family should be specifically included in the transition plan because of the importance those cultures place on family relationships. Self-help models of treatment may need adaptation for different cultures and for women.
Ideally, staffing patterns at all levels of the treatment system should reflect the population served, from clerical staff through executive management. Specific efforts should be made to recruit and maintain such staff members. Licensing, certification, and credentialing should support the use of culturally competent staff, and support continuing education in the knowledge and skills relevant to the population. Staff members should be able to communicate in local languages and dialects, and published materials and consent forms should be available in these languages as well. If this is not possible, staff members should find creative means to compensate for this deficit, although family members, especially children, should never be used as interpreters. Incentives that encourage culturally sensitive client interactions should be woven into the employee performance evaluation system.
Whether the differences are cultural, medical, age-, or gender-related, it is important to remember that offenders are not a homogenous population. This chapter will help community treatment providers and correctional workers deliver effective transitional services to groups with special needs.
In 1997, slightly less than 8 percent of those incarcerated were women -- 6.4 percent of the prison population and 10.6 percent of the jail population (Bureau of Justice Statistics, 1998), but that percentage is rising. Women are substantially more likely than men to serve time for a drug offense rather than a violent crime.
Compared to men, women are more heavily drug-involved (Drug Use Forecasting, 1997), and are often polydrug and intravenous drug users, though they use less alcohol than men. Women in prisons in 1996 were most likely to be black (46 percent), ages 25-34 (50 percent), unemployed at the time of arrest (53 percent), and never married (45 percent). In State prisons in 1991 more than 75 percent of the women had children; two-thirds had children under the age of 18 (Bureau of Justice Statistics, 1994).
Incarcerated women and women with substance use disorders are more likely to have suffered physical and sexual abuse (Hein and Scheier, 1996; Miller et al., 1993; CSAT, 1998a). Incarcerated women's physical health profiles include a high incidence of HIV/AIDS and other STDs, pregnancy, and certain types of coexisting mental disorders. The most common mental health disorder among female offenders is depression. At the Turning Point Alcohol and Drug Program for women in Oregon, approximately 50 percent were diagnosed with depression (Edens et al., 1997) (see box). Another commonly found disorder is post traumatic stress disorder, not uncommon in victims of physical and sexual abuse. The importance of addressing women's health care in correctional settings is spelled out by the National Commission on Correctional Health Care's (NCCHC) position statement on Women's Health Care in Correctional Settings. In it, NCCHC recommends, among other things, intake procedures that include gynecologic history and nutritional intake, pregnancy tests, tests for STDs, and available counseling for depression, substance use disorders, and other disorders common to incarcerated women (National Commission on Correctional Health Care, 1994).
Until recent years, substance use disorder treatment programs for women have been slow to emerge in correctional institutions and in the community, and many institutions still have no women-specific treatment services. Those services that are available often evolved from models developed for men.
Incarceration disrupts relationships with children, as well as with a spouse or partner. If a woman is a single parent involved in drugs and criminal behavior, a child protective service agency generally steps in after the arrest to take control and custody of dependent children. A high percentage of mothers have their children permanently removed from their custody as a result of their incarceration. Parental rights for mothers (perceived as chief caretakers) are scrutinized closely by social services and foster care workers. In some jurisdictions, women have been increasingly criminalized for using drugs when pregnant.
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Model Program: The Turning Point Alcohol and Drug Program |
The Turning Point Alcohol and Drug Program at the Columbia River Correctional Institution in Oregon is a 50-bed therapeutic community for women housed in a minimum security State prison. Originally designed to provide only substance use disorder treatment, high program dropout rates due to mental health problems led to the integration of mental health services. About 60 percent of the women in the program are dually diagnosed. Of those, approximately 70 percent have been diagnosed with post traumatic stress disorder, 50 percent with depression, and 15 percent with bipolar disorder.
Operated by ASAP Treatment Services, the program is structured in five phases that last from 6 to 15 months during the prerelease period, with an average of 7 to 8 months. Each week, at least 30 hours of treatment and educational services are provided. Group sessions incorporate life skills training, relapse prevention strategies, and substance use disorder education. There are 10 counselors on staff with areas of expertise in assessment, family therapy, mental health counseling, and traditional substance use disorder counseling. |
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