Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System
Treatment Improvement Protocol (TIP) Series 12

Pretreatment Services

These services, which are not part of primary treatment, include primary prevention and early intervention.

Primary prevention. These are services for persons who have not yet used AODs. Most primary prevention programs are in schools or the community, but some have been placed in correctional systems.

Early intervention. This may be a psychoeducational approach for people who have used AODs and are considered to be at high risk for AOD-related problems or have a history of AOD use, or it may be a screening process used to identify early AOD use problems. It is also appropriate for AOD-using persons who do not meet the diagnosis of an AOD use disorder. This approach may be used for ongoing evaluation for possible referral to a more intensive level of care. In some instances, early intervention can be used as short-term treatment for those whose AOD problem is of low severity.

Outpatient Treatment

Also referred to as ambulatory care, outpatient treatment provides a broad range of services without overnight accommodation. Some of these services may be provided following inpatient or residential treatment or may be recommended after such treatment for continuing care.

Nonintensive outpatient treatment. This is AOD-focused treatment that includes professionally directed evaluation and treatment typically of less than 9 hours per week in regularly scheduled sessions. Nonintensive outpatient treatment may also address related psychiatric, emotional, and social issues.²

Intensive outpatient treatment. This is AOD-focused, professionally directed evaluation and treatment of 9-20 hours per week in a structured program. These programs may be evening programs, and frequently include some weekend programming.

Methadone maintenance treatment. This is a medically supervised outpatient treatment which provides counseling while maintaining the client on the drug methadone. This regimen is used primarily for heroin or other opiate addiction and provides a legitimate, closely monitored substitute for illegal or other prescription drugs. The client must be able to document at least a 2-year history of addiction to qualify for a methadone maintenance program.

Day treatment or partial hospitalization. This is AOD-focused, professionally directed evaluation and treatment of more than 20 hours per week in a structured program. This is the most intensive of the outpatient treatment options and can be used for treating patients who demonstrate the greatest degree of dysfunction but do not require inpatient or residential treatment. Evening and weekend programming may be included.

Inpatient Treatment Options and Residential Care

Inpatient treatment options include intensive medical, psychiatric, and psychosocial treatment provided on a 24-hour basis. The continuum of residential care includes psychosocial care at the most intensive end and group living with no professional supervision at the least intensive end.

Medically monitored intensive inpatient treatment.³ This level of care involves around-the-clock medical monitoring, evaluation, and treatment in an inpatient setting. It is used for patients who have acute and severe AOD use disorders and who may also have a coexisting medical or psychiatric problem. Such treatment generally involves a short-to-intermediate length of stay (7 to 45 days) and may include nonmedical or social model programs with variable lengths of stay.

Medically managed intensive inpatient treatment.3 This level of care involves around-the-clock, medically directed evaluation and treatment in an acute-care inpatient setting. This level of care is appropriate for the treatment of medical and psychiatric problems that may require biomedical treatment (such as life support) or secure services (such as locked units). Such treatment generally involves a short-to-intermediate length of stay (7 to 45 days).

Short-term nonhospital intensive residential treatment. This treatment is generally 21 to 45 days in length and is designed to teach the client how to live an AOD-free life and to provide motivation for the maintenance of such a lifestyle. Followup care on an outpatient basis and continued participation in peer support groups is recommended to maintain the recovery process begun in the residential setting.

Intensive residential treatment. This long-term (6 to 24 months) treatment model may be directed by an AOD treatment professional or may be medically directed. The model is similar to the therapeutic community model. It is appropriate for persons with multiple problems, especially those with dual disorders involving a personality and an AOD use disorder. The goal of psychosocial rehabilitation is always part of treatment.

Psychosocial residential care. This is a long-term (6 to 24 months), professionally directed, psychosocial care model. The model is also similar to the therapeutic community model and relies heavily on peer pressure as well as formal treatment to shape behavior. It is appropriate for persons with AOD abuse problems and concomitant disorders that do not require acute medical or psychiatric intervention. Persons compliant with psychiatric and other prescription medications may be appropriate for this level of care. The focus of care is on psychosocial rehabilitation.

Therapeutic community. The traditional therapeutic community is a long-term (15B24 months) rehabilitative model that relies primarily on peer staff (usually those who have been rehabilitated by the program) and on work as education and therapy. Other staff include treatment and mental health professionals and vocational and educational counselors. Because the aim of the therapeutic community is a global change in a person's lifestyle focused on the development of vocational, educational, and social skills, it is appropriate for persons with AOD abuse problems and chronic deficits in those areas. Most residents have been involved with the criminal justice system.

Halfway house. A halfway house is a residential, transitional living arrangement with minimal treatment in which residents are supervised by paid staff. Residents may work and receive education, training, or treatment in the surrounding community, although some treatment may be provided in the house. House responsibilities are shared, and rules must be followed. The length of stay may be limited or unlimited, contingent on the attainment of specific progress goals.

Group home living. This refers to a residential, transitional living situation without any specific treatment plan and minimal staff supervision. It is sometimes known as a three-quarter-way house. Residents may work and may receive education, training, or treatment in the community. House residents generally decide on admission of new residents. House responsibilities are shared, and the house is governed and run by its residents. The length of stay is generally unlimited as long as abstinence from AOD is maintained. The Oxford House model includes complete resident self-governance and self-sufficiency. The key to success in all such models is that the living situation is AOD-free and thus supports resident abstinence.

Detoxification

Clients requiring detoxification may be treated in inpatient, residential, or outpatient settings. A client's particular psychosocial circumstances, personal characteristics, or addictions may mandate inpatient care. The process begins with an assessment of the client's need for detoxification and a determination of the most appropriate site for the provision of such treatment. Whether it is conducted on an outpatient, residential, or inpatient basis, detoxification should be monitored by appropriately trained personnel under the direction of a physician who understands the possible consequences of detoxification and has specific expertise in the management of withdrawal and abstinence.

Intake

Intake counselors and other staff require training to ensure that treatment begins with the client's initial contact with the program. This first step in the treatment process should be to put the new client at ease and provide a brief overview of the program's parameters, such as length of treatment, treatment expectations, and program philosophy.

Screening

The screening process begins at intake and extends through the conclusion of the assessment process. Screening often entails a brief interview and the administration of a standardized, validated screening questionnaire to identify the appropriate treatment level. It is at this point that the client and the evaluator answer the following questions: "What services are needed?" and "What program is the best match for the client?"

It is best if the screening process and initial decisions regarding the most appropriate treatment setting are made by an individual or agency that has no financial stake in a particular placement, thereby avoiding a conflict of interest or the appearance of one.

It is essential that screening for communicable diseases (HIV, TB, and sexually transmitted diseases) be an integral part of the initial screening and assessment process. This counseling and testing may be done on site by the criminal justice agency, an intermediate case management agency, or the AOD treatment agency. It may also be done by agreement at a public health counseling and testing site. Formal agreements are necessary to ensure that screening for communicable diseases is offered to all AOD-abusing offenders.

Assessment

The assessment process involves a more in-depth evaluation of the client, lasting one or more sessions, including confirmation of the client's treatment referral and an individual and family psychosocial assessment. This step in the treatment process will give the clinical staff an understanding of the needs of the client, his or her motivation for treatment, and what substance use and other mental disorders may be present. The assessment provides a basis for developing an initial treatment plan.

In conducting the assessment, information should be obtained from multiple sources (such as the client, family members, significant others, counselors, probation officers, peers, and the client's employer), with the aid of multiple methods (such as self-administered questionnaires, interviews, and urinalysis). A comprehensive evaluation should address the following content areas: AOD use and treatment history, signs and symptoms of AOD abuse, intra- and interpersonal factors, environmental factors, medical and mental health status, educational status, employment status, and legal status.

The program's confidentiality regulations should be explained. The client will then be asked to sign a release of information and a form indicating consent to receive treatment. The program's grievance policies should also be explained, as well as how abstinence is monitored (for example, by urinalysis). Finally, the program's guidelines should be explained, as described below.

Treatment Planning

Group Therapy

Group therapy involves peers in a group process that encourages them to address personal issues and the consequences of their AOD involvement. Unlike self-help groups, therapy groups are led by counselors. Group therapy is designed to solicit the involvement and support of others and to encourage healthy interaction. Through sharing, discussion, and problem solving, clients can begin to recognize denial and other signs of minimization and take responsibility for their AOD problems.

Family Therapy

Families benefit from individual sessions, with and without the client present. Substance abuse often reflects family dysfunction and family tolerance of AOD use. For the client living with or dependent upon the family, recovery is difficult without the active involvement and support of the family. Family sessions address how the family must change its patterns of behavior and communication, values, and problem-solving strategies.

Individual Therapy

Clients may need to receive individual therapy in addition to group and family therapy. Some clients are too withdrawn and socially uncomfortable to benefit from the group process, and they require individual therapy. Individual therapy helps clients: 1) cope with obstacles to utilizing group and family therapy and self-help groups, 2) discuss specific issues that they may not be ready to discuss in a group context, 3) improve the treatment alliance, and 4) help correct interpersonal difficulties and weaknesses.

Case Management

Case management is a term used by both the criminal justice and AOD treatment systems because both systems have recognized the great need for coordinated services. For clarity, it would probably help to refer to "AOD case management" and "justice system case management," and, perhaps, "combined case management." The term, case plan, is used only by the justice system. Treatment plan is an AOD term. (Case management is further discussed in succeeding chapters of this TIP.)

Case management provides linkages with other service providers or between systems (such as the criminal justice system and the treatment program) in an effort to assist the client with his or her special needs. It is conducted by a designated case manager, who is responsible for coordinating all aspects of the treatment plan. Case management involves collaboration and networking with other agencies in the community to fill the gaps in services not offered by the treatment program. The range of supplementary services may include domestic violence services, medical care, dental care, housing assistance, mental health treatment, help in preparing Federal and State assistance applications, and childcare, as well as legal, educational, and vocational services. Helping the client and family negotiate the various service systems and coordinating the referral process are vital aspects of case management.

Many clients and families have several psychiatric, psychological, social, economic, and medical problems that will complicate recovery. Coordination, treatment planning, and decisions about how to divide tasks among various agencies require the attention and skill of case managers. Their involvement can help families and clients become more functional and more organized.

In the case of offender-clients, interagency case management becomes especially critical. Such clients are usually in treatment because of a court order and are typically under the continuing supervision of agents of one or more correction agencies. (For example, the offender may already be on probation or parole for one crime and on pretrial release status for another.) Client behavior while in treatment, including completing the treatment program, has significant consequences for the client's future. Expectations of the agencies involved, such as reporting requirements and appropriate responses to program rule violations, must be clarified and confirmed in writing. (This topic will be covered in detail in succeeding chapters.)

The coordination of case management among various service providers may take the form of interagency agreements, including ongoing group case management meetings with agency representatives. Treatment programs should not wait for these systems to initiate such collaboration, but should begin the process themselves. The development of a coordinated case management protocol can enhance treatment effectiveness by decreasing the possibility that:

• Clients will manipulate the various systems providing services,
• Clients will perceive that the system "doesn't care" (since key concerns may have been insufficiently addressed), and
• The various systems will implement strategies that result in conflicting, duplicate, or contraindicated services.

Case management meetings can be particularly important when the client has other diagnoses in addition to AOD abuse. For example, if a client is HIV positive and has AOD problems, meetings with the agencies that provide medical care and support services may be necessary. Similarly, if there is a dual diagnosis -- AOD abuse and a mental disorder -- coordination between the treatment program and a mental health program is usually required. Few treatment programs can offer the needed mental health services themselves.

In all contacts with other agencies and individuals, there must always be respect for the client's right to confidentiality. This is particularly pertinent to issues of substance abuse, sexuality, and health problems such as HIV. (See Chapter 7 for a full discussion of the legal and ethical issues surrounding client confidentiality.)

Drug Testing

Clients in treatment may minimize, deny, or otherwise distort the extent of their AOD use. To determine recent use, to be able to confront use during treatment, and to provide information about relapses, frequent urine drug screens may be helpful. Testing all clients at intake, random screening during treatment and continuing care, and designated screening when the therapist believes a client is deceptive about use are suggested. However, urinalysis screens measure only recent use, and do not provide information about the onset of substance abuse, the rate of use, or the quantity of use, except for recent levels. Periodic random testing may be required by the court or other legal authority for the offender-client.

Education Sessions

Education sessions provide an opportunity for the client to learn about the effects of AOD abuse in a nonthreatening setting. Conducted like a classroom experience, these sessions often help people gain insight into their AOD problems and increase their motivation for self-care. They are also effective in decreasing denial and negative feelings about the treatment process.

The topics selected for education sessions will depend on the needs of the client population and the resource capabilities of the program. Referrals may be possible to other community programs for certain groups. Topics discussed in education groups can include the following:

• Medical effects and consequences of drug use and abuse
• The disease model of addiction (including the signs and symptoms)
• Introduction to 12-step programs (for example, step work, traditions, spirituality)
• Denial and other defense mechanisms
• Effects of substance abuse on the family, codependency, and issues of the children of alcoholics
• Thinking errors or illogical thinking patterns
• Human sexuality (When possible, there should be separate male and female groups. Issues pertaining to the problems experienced by gay men and lesbians may need special attention.)
• HIV/AIDS education
• Coping skills
• Communication skills.

Emergency Services

Emergency service is an essential treatment component when working with AOD-abusing clients, some of whom may be suicidal or violent. Programs must make emergency services available by providing the on-call availability of medical and mental health professionals, crisis intervention, crisis management, and referrals to crisis and emergency shelter programs. It is not unusual for clients and families to experience great stress during the early phases of assessment and treatment. Crisis intervention can address these stresses and help the client and family (or significant others) make decisions that are likely to reduce the strain and permit the course of treatment to begin.

Recreational Activities and Peer Socialization

It is important to explore alternative ways to have fun without the use of AODs. Mastering social situations and physical and mental challenges enhances clients' self-esteem and improves their repertoire of social and practical coping skills. Staff can participate in the activities, serving as positive role models for the clients. Many programs employ recreational therapists to coordinate these activities.

Other Specialized Groups

Most persons in treatment have special life problems and individual needs. It is important for programs to be flexible, and to provide group treatment opportunities for them. The need for particular specialized groups will vary greatly depending on the nature of the client population. If a client has a particular need and a group is not available, it may be possible to address the issue in individual treatment or through referral services. Relevant topics for specialized groups are discussed below.

Discharge, Continuing Care, and Relapse Prevention

At the completion of inpatient treatment, there should exist a structured and time-limited outpatient program and planning process that can assist the client in continuing recovery and obtaining ongoing support. This type of program is often referred to as a continuing care program (or aftercare). A smooth transition from inpatient treatment to discharge and then to continuing care requires coordination of goals and treatment, identification of personal signs of relapse, family involvement, and linkages to other services as necessary. The AOD abuse treatment program should be prepared to assist the client if relapse occurs. Relapse does not mean that treatment was a failure. Rather, it can be viewed as a bridge to the provision of new information and an opportunity for emotional and intellectual growth.

A body of knowledge is emerging that focuses on the problems of relapse. Programs need to be sensitive to the warning signs of relapse, strategies (such as stress management) to manage the prolonged abstinence syndrome, and strategies to prevent relapse. For instance, clients should be provided with opportunities to discuss the emotional, behavioral, and environmental stimuli that were associated with their drug use and to develop strategies to counteract these triggering factors. Two elements of relapse prevention are the preparation of a recovery plan, often called aftercare planning, and the client's continued program affiliation after he or she has completed primary treatment. Many continuing care programs have specialized groups for relapse prevention, while other specialized groups focus on making the transition from intensive treatment to a lower level of care.

Multifamily Groups

Like their AOD-abusing family members, families can benefit from group therapy with other families. In this setting, families learn that they are not alone in their present struggles; they are assisted in fostering expectations that treatment will work and are aided in developing solutions to problems. A series of planned presentations is often a component of multifamily group therapy.

Psychiatric Interventions and Services for Dually Diagnosed Individuals

Dual diagnosis or dual disorder are new terms that refer to the coexistence of AOD abuse and psychiatric disorders. A complete assessment will help establish whether a client's disorder is primary to, secondary to, or independent of another existing disorder.

The decision about whether to treat the AOD abuse or the psychiatric disorder(s) first is a difficult one. The general rule is to immediately treat the disorder that is most acute in presentation, that most interferes with present function, that immediately threatens the client's life, or that has an organic origin and can be medically treated. Other circumstances must be considered when deciding whether two disorders, such as AOD abuse and major depression, can be treated concurrently. Treatment planning, consultation, and continued assessments can help address these decisions.

Coexisting psychiatric disorders can interfere with AOD abuse treatment, and if they are left untreated, the client is more vulnerable to relapse. AOD treatment staff should be able to identify coexisting psychiatric disorders and either treat them or provide appropriate referrals for treatment. A consultant may be hired to conduct mental health assessments, or the client may be referred to an outpatient mental health program for evaluation. It is important that staff be aware of the special problems of the person who is dually diagnosed with AOD abuse and a mental disorder. Gathering and sharing clinical data, formulating a diagnosis, and planning intervention for these clients with special needs should be conducted by a treatment team of AOD treatment staff and mental health personnel. Staff should also be aware that some severely ill, dually diagnosed patients tend to be fragile. Transitional confrontational AOD abuse treatment techniques are counterproductive with this group and may exacerbate the concomitant disorder.

Pharmacotherapy for AOD-abusing clients must be accompanied by close observation and monitoring of target symptoms.

Self-Help

Self-help meetings that are appropriate for the age, gender, and culture of clients are frequently of therapeutic benefit. These meetings, which can be utilized during and following primary treatment, are valuable adjuncts to outpatient services for the client during the recovery process. Self-help groups offer positive role models, new friends who are learning to enjoy life free from AODs, people celebrating sober living, and a place to learn how to cope with the stresses and strains of life. A 12-step model is the most common structure of a self-help approach, but others, such as Rational Recovery and religious programs, may be appropriate.

Intervention

In AOD abuse treatment, the term "intervention" refers to an effort by family, friends, or others, along with professionals, aimed at intervening in the progression of an individual's AOD abuse and encouraging her or him to enter treatment. The most commonly used intervention was developed by Vernon Johnson and popularized by the Johnson Institute (Johnson, 1986). The intervention process focuses on convincing individuals that they have an AOD problem, helping them recognize the need for treatment and, eventually, changing their behavior.

Interventions typically are conducted in a carefully rehearsed and controlled meeting with the client, significant others, and perhaps a treatment professional. Interventions that do not include a professional may also be successful. During this meeting, members of the group express their concerns and feelings to the individual about his or her substance use. The goals of intervention are to alert the individual to the perceptions and concerns of the important people in the individual's life regarding her or his AOD use, and to convince the individual that the next step is to receive a formal screening and assessment by appropriate professionals.

Interventions can be powerful and effective tools for motivating an individual to enter treatment and for overcoming the denial of family and others about the individual's AOD problems. Moreover, interventions can take the form of social or institutional leverage. For example, pressure from the courts, probation officers, employers, schools, and families can be used to encourage the resistant individual to seek treatment.

Caution should be exercised when interventions are conducted by professionals who are also employees of the treatment program. Such a situation may discourage objectivity on the part of the intervention specialist, who may be overly focused on referring a client to his or her treatment program.

Educational or Vocational Services

Increasingly, vocational training, general equivalency diploma programs, and job readiness training are being added to treatment programs, because of the needs of many clients to enter the job market. If programs do not offer these services themselves, they may link up with community agencies that can provide them.

Residential Criminal Justice Programs

Community-based, residential programs are available as sanctioning options in many communities. Their use is growing, particularly as an alternative to revocation for probation and parole violators. Residential facilities can vary considerably in size, ranging from small halfway houses for 20 to work-release facilities that house several hundred offenders. The names of these programs vary as well. Depending on the jurisdiction, intended population, and purpose, the residential programs may be called: diversion centers, prerelease centers, halfway houses, work houses, restitution centers, and reentry houses. The facilities can be managed by the sheriff, community corrections officials, the probation agency, private contractors, the parole agency, or the State corrections agency.

Treatment can be effectively provided in any of these programs. Whatever the setting, these treatment programs have some common characteristics:

• Their mission is to provide control and structure in settings that are less restrictive and less costly than either long-term residential treatment or incarceration, but that can still provide some measure of incapacitation.
• The goals for the offender-client are short-term, involving behavior change that can be initiated while the offender is in the setting and continued after he or she leaves and is on the road to rehabilitation.
• The programs incorporate a treatment plan and provide for case management, treatment, and employment and education services.

The offender in these settings must participate in treatment, must work or attend school outside, and must manage money to pay rent and other obligations such as restitution and child support. Some programs offer additional services to enable the offender to obtain a general equivalency diploma and acquire vocational and general life skills.

AOD abuse treatment is much more likely to succeed for offender-clients if all of these community-based facilities make available an array of services, including education, job training, opportunities for spiritual growth and development, and training in life skills. Programs should emphasize planning for relapse prevention and aftercare (care that continues after discharge from the treatment program). Many programs offer aftercare themselves. Offenders who complete the program can come back after discharge for continuing care or to attend Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings that are part of the treatment program. All continuing care plans, however, should link offenders with community resources that can be used to help them maintain drug-free lives.

Treatment Within Probation and Parole Supervision

Probation and parole agencies are faced with increasing numbers of offenders under supervision who have been ordered to participate in outpatient AOD abuse treatment but for whom no treatment slots are immediately available. Many agencies have chosen to offer AOD abuse treatment within their own agencies. To this end, the agencies have secured training for their officers to become certified counselors and have begun to provide outpatient treatment of various intensities for the offenders under their supervision.

Having treatment services available onsite increases the ability of the agency and its regular agents to direct offenders into treatment in the absence of a court order: The treatment can be part of the overall supervision strategy. It can also be cost effective for the agency (or the court), since fees do not have to be paid to outside service providers.

There are those both in criminal justice and in the treatment community who question the wisdom of this approach. If the offender-client views the agency primarily as a punitive law enforcement organization, treatment can be difficult, and few such agencies can offer the range of kinds of treatment services that are needed. Some in the criminal justice system also take the view that corrections and the courts ought to be advocates for increased treatment opportunities in the community for everyone rather than taking on the responsibility of making up for the insufficient treatment on the outside by providing it inhouse.

Specialized Caseloads

In some jurisdictions, probation and parole agencies have responded to the increasing numbers of AOD-abusing offenders under supervision by creating specialized caseloads that group offenders according to a common characteristic or need for purposes of supervision. (As indicated earlier, specialized caseloads have been created to handle a wide variety of types of offenders.) Several types of specialized drug-offender caseloads have been established in jurisdictions around the country, and their use is growing. In some agencies, they are used in conjunction with agency-provided treatment services; in others, the caseloads are intended for offenders who are receiving treatment elsewhere in the community or who are in aftercare.

Specialized caseloads have several common characteristics:

• A probation or parole officer providing the supervision who has the training needed to understand and respond to the needs of the offender-clients;
• Manageable client-to-officer ratios;
• A case plan, developed as part of the presentence or preparole investigation, that is adjusted regularly by the supervising officer;
• A focus on drug offenders;
• Case management, based on the agency's classification process, which is used consistently;
• Assessment for treatment provided by someone other than a probation officer, preferably before sentencing or parole; and
• The ability to call upon other professionals -- such as doctors, psychologists and other mental health professionals, teachers, job trainers, and financial needs consultants -- for additional assistance or services.

The best officers to handle these caseloads are those who understand the process of linking a variety of services together through case management and who can make connections to other professionals in the community for assistance.

Probation and parole officers responsible for specialized caseloads must have administrative support and the backing of their supervisors. The work is very draining, and many officers experience burnout as a result of their attempt to see that the needs of everyone in the caseload are met. The issue of staff burnout should be addressed as part of the program's overall design. That design should include ongoing training and support for officers.

Day Reporting Centers

A typical day reporting center is a facility for people who are permitted to live at home, but required by the terms of their probation or parole to be at the facility for a specified period each day.

Some day centers function primarily as staging areas from which offenders are sent out in work crews to perform manual labor in the community: cleaning highways, painting schools, and the like. Others offer chiefly educational opportunities. In many jurisdictions, however, day centers have become day treatment centers whose primary mission is to provide outpatient AOD abuse treatment of various intensities. That treatment may be provided by public or private treatment agencies, or by staff of the correctional agency. Day centers can, of course, offer a combination of these activities plus additional ones.

Home Confinement

Home confinement can be ordered as an accompanying condition with any of the other nonresidential programs described here. The offender must remain within his or her home except for the specific times or activities permitted by the court or paroling authority. Home confinement or curfews are often monitored by means of electronic devices that permit parole or probation agents to verify their presence in (or detect their absence from) the house.

Both home confinement and day reporting centers provide significant restrictions on offenders' liberty and opportunity to commit crime, but are not as restrictive or punitive as a residential program or incarceration. At the same time, they permit the offender-client access to a wider array of treatment options than might be available in a residential correctional setting.

Self-Help and Support Groups

An important adjunct to treatment is the self-help group, including 12-step programs. Self-help groups, however, are not treatment programs. The best known are Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous. Many treatment programs are based on what is called the 12-step model of treatment, and attendance at 12-step programs is required of people in treatment. All 12-step programs are modeled after the earliest -- AA -- which is a spiritually based program of recovery. Members "work" each of the 12 steps, which means making each step an inherent part of one's life. Persons who have difficulty with the spiritual basis of AA may prefer other self-help groups such as Rational Recovery or Women for Sobriety. Self-help groups are sometimes established based on ethnicity or gender. No matter who belongs to them, self-help groups are separate from either treatment or the criminal justice system, and they are operated by their members.

In the early years of efforts to overcome alcohol and drug abuse, the self-help groups, particularly AA, were the only resource available to persons with AOD abuse problems, and they are still recognized by virtually all treatment programs as a very significant and necessary adjunct to treatment.

The criminal justice system has recognized the importance of AA, NA, and the others. Many judges require offenders to attend them as a condition of their sentences; parole boards often require attendance as a condition of parole release. In a few localities, AA and NA have allowed monitors to sit outside to ensure that offenders attend meetings. AA or other 12-step groups can be provided in a justice institution or community-based facility in conjunction with treatment or as part of the recovery plan.