Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System Treatment Improvement Protocol (TIP) Series12
Successfully combining alcohol and other drug (AOD) abuse treatment and intermediate sanctions requires sufficient, flexible services; good information; well-informed collaboration; and mutual understanding.
There are several basic prerequisites for ensuring that courts make the optimum use of AOD abuse treatment in the context of intermediate sanctions and that offender-clients get the treatment services that they need.
First, judges, prosecutors, probation agencies, and defense attorneys need a reliable, easily accessible means to assess the treatment needs of the offenders for whom they are choosing sanctions.
These assessment services may be provided through an interagency agreement with the State AOD agency, by specially trained probation officers, or by contract with another outside agency.
The assessment process should produce an individualized plan for comprehensive AOD treatment, along with recommendations for appropriate and available treatment services.
Second, an array of intervention strategies and treatment modalities should be available to the court for use as part of the sanctioning package.
If choices are limited, then some offender-clients will receive treatment that is inappropriate or ineffective for the developmental stage of their illness.
Third, the services must be expansive and flexible to meet the many needs of offender-clients.
The more responsive programs are to all of these needs, the more likely that the overall outcome will be positive for the offender-client.
Fourth, programs that provide treatment must be willing to work with court and criminal justice decisionmakers to explain the possibilities and the limitations of their services.
Such interaction can help ensure appropriate referrals and more accurate expectations and help maintain the credibility of both the programs and the treatment system.
Fifth, education needs to be provided to judges and other criminal justice decisionmakers to help them understand the typical behavior patterns of AOD abusers and respect the system of incentives and consequences employed by treatment programs to respond to client behavior.
This information will help the court maintain realistic expectations of offender-clients in treatment and prevent inappropriate justice system responses to that behavior.
One of the most frequent mistakes in treatment is to place patients in treatment programs that are not appropriate to the developmental stages of their illness.
Misreferrals often result when there is a waiting list of prospective clients, and each is placed in the particular opening that comes up, irrespective of the type or phase of treatment offered.
For example, a moderate drug user who recognizes the threat of drug abuse to his life and wants to quit can be doomed to failure by placement in a residential program.
All he may need is education and counseling provided in an outpatient program.
It is inappropriate to ask him to leave his family, forget the outside world, and learn how to live within the controlled environment of a treatment center.
Because treatment and activities in the residential center are very restricted, misdirected clients are likely to become hostile and their treatment fails.
Such offenders should be referred to outpatient treatment for a specified number of hours a week, thereby keeping their family system intact.
This type of misreferral happens frequently in the justice system because of the system's need to balance competing or conflicting goals in crafting a sanction.
An offender who commits a relatively serious offense but whose AOD abuse problem is only moderate poses a dilemma to the court.
In the interest of adequately punishing the serious offense (and/or limiting his or her access to the street) and of treating the offender's underlying problem, the court might choose a sentencing package that includes long-term, residential treatment even though the offender-client's problem does not warrant such a restrictive, intensive response.
It is possible to deal with these dilemmas, but all of the parties (judges, prosecutors, defense attorneys, probation staff, and treatment providers) must agree on the goals and outcomes for specific groups of offender-clients.
The offender groups must be clearly identified by types of crimes, criminal history, and demographic characteristics.
For example, a jurisdiction may need a residential facility that provides both intensive and nonintensive AOD abuse treatment for male offenders, over age 30, with multiple felony convictions, and a current felony property conviction.
Such a facility would offer significant restrictions on liberty, severe limitations on residents' opportunity to commit crime, and a variety of treatment responses.
At the same time, the jurisdiction might also need a day treatment center that offers intensive outpatient AOD treatment to offender-clients who do not require as much punishment and/or incapacitation. The jurisdiction must determine the types of offenders for whom it wants to provide treatment and the relative priority of treatment among other criminal justice system goals.
Experience gained to date in the provision of treatment to offenders suggests the critical importance of collaboration and effective communication between the justice system and the AOD abuse treatment system.
Indeed, experience shows that working together needs to be a major goal if effective treatment is to be provided to offenders.
Because treatment is part of the health care and social service fields and focuses on the "whole person," treatment providers are more interested in the person than in the crime committed and its consequences.
In contrast, the criminal justice system focuses on the person within the context of the whole community: What harm has been caused by this person and to whom.
What are the consequences of her or his continued presence in the community.
What is the message to the community if we do or do not incarcerate her or him.
The justice system's primary concerns -- and responsibilities -- are the larger society and its safety.
Treatment is concerned with determining what led to the individual's overall behavior as well as the crime, with the hope that understanding can lead to changes in that behavior.
Treatment personnel speak of holistic treatment, meaning that if they can deal with all the issues pertinent to the individual's behavior and values, it will be possible to treat her or him in a manner that leads to elimination of the undesirable behavior.
The justice system is usually just as concerned about changing undesirable behavior.
The chief difference is the origin of the concern: The justice system wants a safer community, and the treatment provider wants a healthier individual.
In the end, both can acknowledge that treatment is a necessary means to protecting society by addressing individual problems that lead to crime.
While the desired result -- the individual in recovery and leading a life free from crime -- may be shared, the two systems operate from very different concerns and responsibilities.
These in turn produce very different operating principles, values, and procedures.
While collaboration cannot do away with these differences, nor would we want it to, it can help to overcome the unnecessary barriers and misconceptions that hamper effective service delivery, the shared goal of the two systems.
The justice system wants a safer community, and the treatment provider wants a healthier individual.
In the end, both can acknowledge that treatment is a necessary means to protecting society by addressing individual problems that lead to crime.
Some guidelines can be provided for agencies that attempt to work together:
Ensure that personnel in the treatment system understand the intent of sentencing for each offender.
To avoid "turf" problems, ensure that those in each system clearly understand the scope and responsibilities of both the justice and treatment systems.
Understand the other system's view of the individual offender.
Be clear about which system's discipline will prevail in which situations.
Communicate clearly and work to develop a common language.
Understand how perceived treatment failures can constitute a violation of the law.
Agree on the features of the case plan.
Understand the terms and conditions facing the offender-client.
The justice system endeavors to ensure that sanctions are consistent with the intent of the sentence.
In considering collaboration, the question of the goals of sentencing becomes very important.
Treatment personnel need to ask, "What is the court trying to achieve for this individual by this sentence?" Too often, issues of intent are not discussed and only later do justice and treatment discover that they were starting from different premises.
The intent and goals of sentencing come into play on two levels.
First, it is crucial that treatment providers understand the full terms and the purpose of the sentence in each case in which they are involved.
The more specific the court can be about the outcomes that are desired, the easier it will be for the provider to meet those expectations.
This may require that the program or counselor contact the court (starting with the judge's clerk or bailiff) or the probation officer to get this information.
The more specific the court can be about the outcomes that are desired, the easier it will be for the treatment provider to meet those expectations.
The criminal justice decisionmakers in each case have a responsibility to spell out what they want to happen with the offender and why.
It is not enough to agree or order an individual "to get treatment" or even "to get outpatient treatment." The order or agreement should articulate how often treatment is to be provided (daily, three evenings a week, or whatever), in what kind of setting (a residential treatment facility, a residential criminal justice facility, an outpatient facility, a day treatment center, and so on), and to what extent other goals besides treatment have been set.
For example, it should be clarified whether the offender has been ordered to report to a day treatment center because the assessment indicated she or he needs that intensive level of treatment or because the decisionmaker wanted her or him kept off the street for 8 or 9 hours a day or both.
Second, the justice system decisionmakers responsible for crafting sentences in individual cases -- the judge, prosecutor, defense attorney, and probation officer -- must understand the capabilities and limitations of the treatment program's services.
They must be familiar with its procedures to the extent that these will affect the court's expectations.
In the example cited above, the day treatment center or day hospital may not be able to offer the level of security the court desires.
If the court is not familiar with the specific features of that program, the level of incapacitation that was intended for the offender-client may not be achieved.
This can have a negative effect on the perceptions of justice system personnel regarding treatment providers.
Treatment providers have to be responsible for informing judges, parole agencies, and other justice system decisionmakers about available treatment programs and what they can and cannot accomplish.
Treatment providers have to be responsible for informing judges, parole agencies, and other justice system decisionmakers about available treatment programs and what they can and cannot accomplish.
Opportunities for disagreement are frequent in any case in which treatment providers and the criminal justice system are both involved.
Nowhere are those opportunities greater, however, than when a treatment program is operated within a residential corrections facility such as a prerelease center or work house.
The offender-client in treatment in such a setting may feel like the child who has two parents who do not always agree on what the rules are and how they are to be enforced.
Such disagreements typically arise when the goals and objectives of the two systems are in conflict.
Within a correctional facility of any kind, the primary responsibility of its managers is security.
This includes protecting the security of the surrounding community by controlling the whereabouts of offenders at all times, and protecting the security of the offenders by having an orderly, clean, and well-controlled facility.
For treatment providers, whether they are employees of the facility or outside contractors, the responsibility of assisting offender-clients through the difficult and painful process of recovery may mean wanting the rules to be flexible and facilitative of what is best for the individual client.
While the treatment provider has to understand that security is the chief priority within a correctional facility, the corrections staff can appreciate that a successfully treated offender is less likely to commit crime following release.
One step that can foster collaboration and success is the establishment of interdisciplinary teams to work together to make decisions based on the best information.
To the treatment provider, relapse is a step in the process of recovery.
To the court, it may be considered a violation of the law or a violation of the conditions of the sentence.
The two communities need to better understand each other's positions on factors such as relapse.
When an offender-client receives a sanction that includes treatment, a perceived program failure can constitute grounds for revocation.
Missing scheduled outpatient treatment may be considered a violation of probation or parole by those in the justice system, while treatment personnel may view it as part of the denial process, a common condition in treatment and recovery.
Such distinctions need to be discussed and clearly understood, both by those working in treatment and by those working in justice, as well as by the offender-client.
A treatment contract should cover issues of negative behavior, as well as the rewards associated with compliance and eventual successful completion.
If the probation department and the court have made a referral to a treatment provider, the issue of program failure has to be addressed when the memo of understanding or other agreement is developed, so that an agreed-upon, common response can be developed.
The use of contracts is very important to inform the offender-client clearly what the consequences will be if she or he is found to be noncompliant with rules and regulations.
The offender and the treatment provider must understand what behaviors will get her or him back in court or lead to a different sanction.
Guidelines might be clearly stated as follows:
Every program has a set of rules and expectations, and the client will be in jeopardy if he or she fails to comply with those rules and expectations.
Any law violation means the client-offender is in jeopardy status.
Compliance with all the conditions of probation or parole, particularly special conditions arising from the offender's crime, is mandatory.
Failure to appear in court as directed constitutes a violation of the law.
In addition, all due process protections for offender-clients must be specified in writing.
The failure to comply with the requirements of a treatment program does not have to mean automatic revocation.
One program has had success with using defense counsel to intervene.
When a violation occurs, the program informs the defense counsel who negotiates with the district attorney, the probation agent, and the treatment personnel, functioning as an advocate for the offender in bringing about alternative sanctions, such as intensifying the treatment.
Collaboration between the justice and treatment systems to achieve more effective treatment for offenders requires that the two work together to achieve clarity in both their communications with each other and their joint communications to the public, legislators, and other policymakers.
The criminal justice system has to examine its own jargon, which is full of the language of prison and punishment.
In fact, however, most offenders under correctional supervision are in the community, not in prison.
The public has not been educated to realize that everyone who goes to jail and almost everyone who goes to prison will return to the community.
Many will be released within months of their original sentencing.
Legislatures have responded to public fears by enacting tougher sentencing laws, but this has only added to the public's misperceptions about the terms that most offenders serve. (Lest this document contribute to misperceptions, we want to be clear that there are tens of thousands of inmates all over this country who are serving and will serve extremely long sentences in prison.
In terms of all inmates who are admitted to prisons and jails in any period of time, however, most will serve relatively short terms.) If the criminal justice and treatment communities want to increase the opportunities for effective treatment for offenders, one of their first collaborative efforts should be to help educate the public about the realities of offenders in the community.
If the criminal justice and treatment communities want to increase the opportunities for effective treatment for offenders, one of their first collaborative efforts should be to help educate the public about the realities of offenders in the community.
Such an effort is necessary to advocate for the treatment needs both of offenders in the community and of those in custody, since the latter will, in all likelihood, soon be returning to the community.
Offenders and corrections officials need to be reminded of this as well: Incapacitation and rehabilitation are not mutually exclusive.
If an AOD-abusing offender is going to serve time in an institution, it makes far more sense to focus on enabling her or him to be able to function back in society than to concentrate on making her or him into a "good inmate" who can survive within a correctional institution.
Language is also very important to communication between the two systems.
Miscommunication can occur when common words are believed to have a universal meaning but, in fact, do not. "Classification," for example, is used by criminal justice practitioners as if it were synonymous with "assessment," which is the expression used most commonly by treating professionals.
The differences in these terms are important.
Classification usually refers to a system for determining how much supervision an offender requires because of the risk she or he represents.
Assessment is usually associated with a determination of the social, psychological, or healthcare needs of an individual.
Criminal justice agencies also conduct clinical assessments for their own service delivery systems.
Relapse prevention is another commonly used term that generates much confusion between the two systems.
Some in the criminal justice field assume that relapse prevention requires -- and therefore means -- increased surveillance to deter AOD use.
Their belief is that if you increase their chances of getting caught, offenders will not relapse.
To treatment providers, relapse prevention is problem solving -- a process of understanding the individual's patterns of AOD abuse and the pressures or triggers that can cause it, and then creating individualized strategies to deal with those issues.
Corrections agencies must have policies and practices in place that foster understanding of the goals of treatment and the treatment process, and that support the role of the treatment program as a partner in carrying out the case plan for each offender-client.
If these are left to the discretion of each officer, problems will result.
An offender under the supervision of one probation officer, for example, may be progressing in treatment very well.
He or she may then be transferred to another officer who may not understand or support treatment and who may have the attitude that, "You screw up one time, partner, and you are back in the slammer." The intent of treatment in this case may be jeopardized.
Many probation and parole officers embrace treatment options as being absolutely essential, but there are others who doubt treatment's value.
Treatment programs must educate corrections agencies about treatment and their individual services.
The burden, however, should not fall exclusively on the treatment providers.
Corrections agencies have an obligation to develop uniform policies and training for their staff in this critical area.
It is rare for the client in probation not to be facing other terms and conditions in addition to participation in the AOD abuse treatment program.
Typically, the terms and conditions of probation or parole might include:
Obey all laws.
Submit to search and seizure.
Participate fully in the AOD abuse treatment program.
Perform 300 hours of community service.
Pay restitution to the victim of $1,000, in monthly payments.
Pay fines associated with the crime.
In the absence of communication and good case management, both the treatment provider and the officer supervising the offender-client may misjudge the extent of the terms and conditions facing the client, causing her or him to be overburdened and increasing the likelihood of treatment failure.
For example, an offender-client who is doing well in treatment and meeting all other terms and conditions may fail to make monthly payments for restitution for a period of several months.
A probation officer who is unfamiliar with the requirements of the client's treatment may take punitive action such as increasing the amount of each restitution payment to make up for the missed ones.
This will require the offender to work many more hours a week and may negatively affect his or her ability to progress in treatment.
Treatment and probation and parole personnel need to cooperate to prioritize goals and to make sure the client is not overburdened by the sheer number of requirements.
Many offender-clients have been unable to handle much responsibility or meet regular commitments in the past, which may be part of the reason for their current situation.
Virtually all of the elements that have been discussed as necessary to collaboration between the treatment and justice systems can be included as elements of good case management.
A case management approach assumes that the criminal justice agency and the treatment provider view themselves as partners in a common effort to get the offender-client in recovery from AOD abuse and living a crime-free life.
From that starting point, justice system practitioners and treatment personnel can cooperate in setting goals for the offender-client, responding to undesirable or violation behavior, and adjusting the terms of probation or parole and/or the type and intensity of treatment.
Good case management begins with good information: information about the other agency; its responsibilities, policies, and practices; and its expectations of its clients.
This information can reveal important and necessary differences between the agencies and can help build respect for their complementary roles.
Collaboration and case management between treatment providers and probation and parole agencies can be fostered in many ways.
One approach that has been used successfully invites the probation/parole officer to be present during the client-offender's intake process, which gives the officer insight into the client's problems.
Case discussions between the officer, the treatment provider, and the client-offender can be scheduled monthly.
This gives both professionals insight into the client's situation and full range of conditions and prevents the offender-client from manipulating one person against the other.
Using this approach, the officer and the treatment provider share power and decisionmaking.
When treatment and justice personnel have developed collaborative working relationships, their response to negative behavior, such as relapse, is based on trying to achieve their common goals for the offender-client.
The criminal justice system is much more likely to trust clinicians to make decisions; treatment personnel are more likely to base their decision on clinical grounds with full consideration of security and public safety.
In jurisdictions where good case management is practiced, the probation/parole officer and the treatment provider might consider preparing joint reports or appearing together before the court or parole board to address issues pertaining to the offender-client's progress.
This kind of feedback can be helpful to those decisionmakers, not only in deciding the immediate case, but also in making well-informed decisions in future cases.
Criminal justice practitioners are concerned about the licensing of treatment programs.
This concern typically arises when the justice system has had experience with a treatment provider or program of poor quality.
Treatment programs with funding from the State or Federal Government must be licensed.
Programs that operate with private funds do not have to meet recognized AOD abuse treatment standards.
The writers of this TIP recommend that individual States standardize facility requirements and establish minimum requirements for treatment services that would be applicable to all treatment programs.
As part of that regulation process, States should require licensure and monitoring by the State AOD agency or a recognized State board.
The responsibilities of the agency or board should include overseeing and monitoring facilities.
Programs should be required to meet minimum treatment standards, and the State should determine that they are competent to provide services through a formal evaluation procedure established by the regulatory agency.
Criminal justice system personnel are also concerned about the outcome of a particular treatment program or modality.
While licensing cannot guarantee a successful outcome, ensuring that minimum standards are in place and that quality assurance is addressed are necessary first steps.
It would also be helpful if criminal justice practitioners could regularly receive information about the program, the client profile, and the population the program is designed to serve.
In some States, counselor associations provide the certification of treatment personnel or use national certifying bodies.
There may be no enforcement, however, from the State agency regarding this certification.
The State AOD agency may lack the authority to certify and regulate AOD counselors, thus prohibiting the State agency from requiring such certification.
In other States, voluntary boards that are not part of the State AOD agency may provide certification.
In either case, the agency or board should license and regulate private-sector program personnel as well as federally and State-funded personnel.
The issue of using ex-addicts or ex-offenders as counselors also needs to be addressed.
They may make very good counselors, but they need also to be qualified by virtue of training and certification.
The problem of unregulated programs and treatment providers is especially important to criminal justice practitioners whose agencies may face political pressure to use particular programs.
The result may be that clients are placed in substandard treatment for which the daily rate paid by the criminal justice system is the same as that paid to a program offering top-quality and up-to-date services.
Providing AOD abuse treatment to offenders through intermediate sanctions is far more likely to be effective if treatment staff understand the criminal justice process.
It is important, for example, to distinguish between the authority of a written court order requiring treatment and the spoken statement of a probation officer who says, "I don't think you are doing well, and I want you to go to this treatment program."
Understanding the criminal justice process and the individual offender-client's stage in the process are necessary elements of effective treatment planning.
The length of time the offender is to be in treatment, the exact terms of the order or condition, the nature of the offender's accountability and the authority accountable to, and the consequences of behavior are critical pieces of information for the treatment provider.
The more the provider knows and observes about the criminal justice system's expectations and needs, the more likely it is that criminal justice system decisionmakers will develop confidence in the treatment program and accept the program's rules and procedures for accountability.
As noted above, good case management practices between the two systems will contribute greatly to this understanding, cooperation, and mutual trust.
The treatment program needs to know that it can proceed with treatment, respecting the accountability needs of the criminal justice system and receiving respect for its judgments about the appropriateness of criminal justice intervention.
Critical Information for the Treatment Provider
The length of time the offender is to be in treatment
The exact terms of the order or condition
The nature of the offender's accountability and the authority accountable to
The consequences of behavior.
For example, if a client seems to be in a strong recovery, progressing well, and then relapses, program personnel should have confidence that the court decisionmakers will view the relapse as they do, as part of the process of the disease, and will allow the program to design or develop the appropriate response, either in conjunction with the court or with its approval.
Unfortunately, many providers tend to shy away from providing services to offender populations because they fail to understand that the justice system population is really not new to them.
For the most part, offender-clients are people from the same communities as those now receiving treatment from these providers.
The disease has simply progressed further among offenders: They were willing to engage in criminal activities to support their habits or were caught possessing or using drugs.
Many of the offenders in need of treatment, in fact, may have been in treatment before and may be known to staff of treatment agencies.
Enhanced demand reduction efforts have resulted in many more individuals being arrested and incarcerated.
These individuals are now in the criminal justice system rather than in our city streets.
Many providers have also been intimidated by public policies that have identified drug abusers in the criminal justice system as a menace and too severely ill to treat.
After working with this population in the justice system environment, many treatment providers find that, as a group, offenders are very responsive to treatment because they have been close to "bottoming out" in their disease or have already done so (see Chapter 3). Their motivation for treatment is often very high.
Treatment programs have to provide some services to the court or correctional agency that are not ordinarily required for other clients.
Treatment providers may be asked to participate in surveillance, monitoring the resident, and maintaining contact with employers or training programs.
These tasks are usually straightforward, and accepting them as part of the treatment provider's responsibility helps gain the support of the justice system for treatment.
Many clinicians resist these tasks at first, but then find that when they incorporate joint case management into treatment, they have a better understanding of their offender-clients.
Treatment programs and the treatment field have not existed long enough to predict specific outcomes for each program.
Treatment practitioners feel that they are being pushed to become more accountable for results at a time when the field is still defining itself.
Crime and the relationship between crime and drugs have increased the pressure on the treatment field to become more accountable for the outcomes of its programs.
Providers are called upon to forecast what will happen to the client as a result of taking part in particular treatment activities, but they often do not know for sure.
They should be clear that the treatment field is still studying treatment outcomes and identifying factors that lead to effective treatment.
The CSAT Treatment Improvement Protocol series, of which this document is a part, is an effort to inform providers of the best thinking, practices, and research in the field.
Treatment providers also need to keep abreast of new studies from the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Addiction, and private groups such as the Center on Addiction and Substance Abuse at Columbia University.
As study findings emerge, treatment providers should keep their counterparts in the justice system informed.
Once the criminal justice field knows more about treatment outcomes, it will be better able to support treatment as part of intermediate sanctions.
Law enforcement has begun to acknowledge that punishment and prisons alone are not going to solve society's problems with AOD abuse.
Many law enforcement administrators now recognize the positive contributions of treatment, and national figures in the criminal justice field are speaking out about the need for increased support for treatment.
That support, however, depends on two things: criminal justice system leadership that will advocate for treatment and Federal and State funding to establish treatment programs.
To know what types of clients, offenders or not, are most likely to benefit from what types of treatment, good studies on treatment matching are needed.
The research to date, is not consistently clear about what works, and more studies are called for.
Attempts have been made to identify criteria for success at 1-year followup, such as: 1) continued abstinence, 2) no arrest or rearrest for AOD-related offenses, and 3) evidence that AODs are not creating any other problems in the person's life.
The offender does not have to attain success in all three areas: one can relapse and still be considered a success in treatment.
In at least one State where these three measures were used to follow offenders, it was found that about 40 percent remained abstinent, about 40 percent were not arrested or experiencing other life problems, and about 20 percent were not helped (Colorado Department of Health, 1992).
As study findings emerge, treatment providers should keep their counterparts in the justice system informed.
Once the criminal justice field knows more about treatment outcomes, it will be better able to support treatment as part of intermediate sanctions.
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