What follows is the executive summary of the guideline; for more detailed information on the recommendations, please see the original guideline document.
Screening and Assessment
A vital first step in providing substance abuse treatment to people under criminal justice supervision is to identify offenders in need of treatment. In the criminal justice system, screening often is equated with "eligibility," and assessment often is equated with "suitability." To do this effectively, the consensus panel recommends that protocols be developed to determine which offenders need substance abuse treatment, assess the extent of their treatment needs, and ensure that they receive the treatment they need. Obtaining accurate and reliable information during screening and assessment can be a challenge; offenders do not always accurately report drug or alcohol problems. Other collateral sources of information (e.g., drug test results, correctional records) can be combined with self-report information to make referral decisions. For example, in many correctional facilities, urine tests are used to flag the need for treatment--even when an offender denies recent substance abuse.
Many offenders who abuse substances have co-occurring mental disorders that can make treatment more complex. They should therefore be screened for other psychological or emotional problems. Offenders who are initially assessed as having symptoms of co-occurring disorders should be evaluated over an extended period of time to determine whether these symptoms resolve in the absence of substance use.
A significant number of offenders who abuse substances also have histories of trauma and physical or sexual abuse. Screening and assessment of a history of physical and sexual abuse should be conducted routinely, particularly in settings that include female offenders. Staff training is needed to develop effective interviewing approaches related to the history of abuse, counseling approaches for addressing abuse and trauma issues, and in making referrals to mental health services.
Triage and Placement in Treatment Services
Information obtained in screening and assessment is used to place offenders in the treatment program that is best suited to their needs. More offenders can receive appropriate treatment if a range of substance abuse treatment options is provided in criminal justice settings, particularly in institutions and community settings where offenders are supervised for long periods of time. In addition to key information regarding substance abuse problems, risk for criminal recidivism, and mental health problems, triage and placement decisions also should consider the offender's motivation and readiness for change, the length of sentence or incarceration, history of previous treatment, violence potential, and other related security or management issues. The consensus panel recommends that in general, offenders who have moderate-to-high levels of substance abuse problems and criminal risk should be prioritized for placement in substance abuse treatment services, rather than in other types of institutional programs.
Treatment Planning
After placement, a treatment plan is developed that specifies which services the offender-client needs, at what level of intensity, and which of the available resources (e.g., personal, program-based, or criminal justice) will be most beneficial. The treatment plan takes into consideration the severity of substance abuse-related problems and the presence of co-occurring mental disorders because these influence the treatment approach. Also important are factors such as criminal attitudes and psychopathy, which may suggest persistent criminality unrelated to the need to maintain a drug habit. The degree to which an individual is motivated and ready for change is another critical factor that will determine whether motivational enhancement interventions, sanctions, or more self-directed treatments are appropriate. Finally, personal strengths are taken into account in planning. The offender should be involved in the treatment planning process.
The most effective treatment programs have the resources necessary for comprehensive assessment and treatment planning activities including adequate staffing, clerical support, and access to computers and management information systems that contain information regarding the offender. Mechanisms for sharing information among agencies will expedite treatment as clients move through the criminal justice system. For example, monitoring, consultation, and written agreements are needed to define the types of information that will be shared, with whom, and under what circumstances. Procedures that ensure the smooth and timely flow of relevant information will enable staff to proceed with treatment without interruption. Effective management information systems allow for access to clinical information as well as other offender data. At the same time, however, confidentiality regulations require that clinical information be maintained separately from the corrections or supervision case files, and access to clinical files be restricted to staff who have primary clinical responsibilities.
Major Treatment Issues and Approaches
Clients under criminal justice supervision share many of the same clinical issues faced by others receiving substance abuse treatment, but some are unique. For example, many offenders have problems with the very issues that brought them to the attention of law enforcement, particularly, criminal thinking and values. These clients often have problems dealing with anger and hostility and have the stigma of being criminals, along with the guilt and shame that accompany this stigma. Their identity as criminals may need to be offset by exposure to more prosocial values and identities such as those of family member and wage earner.
Adapting Offender Treatment for Specific Populations
General clinical strategies for working with offender-clients include interventions to address criminal thinking and to provide basic problem solving skills; however, substance abuse treatment approaches should be modified to meet specific client needs. Because of their histories or life experiences, certain populations are recognized as having somewhat different treatment needs. For example, people from cultural minorities have had different stresses from those in the majority culture. Women are more likely to have been traumatized by physical and sexual abuse than men and to have urgent concerns about their children. Offenders with co-occurring substance use and mental disorders need help that integrates treatment for both. Other groups with specific needs include older adults, violent offenders, people with disabilities, and sex offenders.
Treatment Issues Specific to Pretrial and Diversion Settings
Treatment varies not only because of the specific population to which an offender belongs but also because of a client's stage in the criminal justice system. After arrest and before trial, a large number of individuals move relatively quickly through the system, and many different agencies are involved with each case and its supervision. If offered, the offender may opt for treatment instead of formal charges, trial, sentencing, incarceration, or to reduce the length of incarceration.
Variations in local prosecution and diversion practices may affect a jurisdiction's ability to develop criminal justice and treatment linkages. Not all jurisdictions have established procedures or programs for individuals who abuse substances; those jurisdictions that do have programs to treat offenders often maintain such programs with limited resources. However, the pressure of overcrowded jails and prisons is serving to expand and institutionalize programs for drug treatment in pretrial and diversion settings nationwide. Still, outside of formal drug court and diversion programs, treatment access is limited. Types of treatment used in the pretrial setting are necessarily brief and include brief motivational interventions, behavior contracts, and referrals to detoxification and other services. A variety of sanctions also are available.
In the pretrial setting, the question of an individual's guilt or innocence has not been legally determined. It is vitally important, therefore, to note that treatment should not compromise the due process rights of defendants. Treatment professionals need to bear in mind the presumption of innocence that exists during the pretrial period. Defendants' due process rights affect what they are willing to agree to and the type of information that they are willing to disclose. Defendants should not be coerced into waiving due process rights, although a court may order substance abuse treatment as a condition of pretrial release.
Treatment Issues Specific to Jails
Those incarcerated in jails are undergoing significant stress related to arrest, the uncertainties of their legal situation, and the potential loss of their job or custody of their children. Appropriate treatment services for these individuals are based on the expected duration of incarceration and the information obtained from screening for a variety of possible problems. Brief treatment (less than 30 days) usually focuses on supplying information and making referrals but can include motivational interviewing. Short-term programs (1 to 3 months) have the time to work on communication, problem solving, and relapse prevention skills; introduce anger management techniques; and encourage participation in self-help groups. Longer term programs (3 months to 1 year) can provide additional skills training, vocational, and educational activities, and examine criminal thinking errors. The consensus panel recommends that jail staff implement discharge planning that includes gathering information regarding the need for a range of community services, including housing and health care.
Treatment Issues Specific to Prisons
The unique characteristics of prisons have important implications for developing and implementing treatment programs. In-prison drug abuse treatment, particularly when followed by community-based continuing care treatment, has been credited with reducing short-term recidivism and relapse rates among offenders who are involved with drugs. More recently, the sustained effects on longer term outcomes have been documented by studies indicating that 9 to 12 months of prison treatment followed by at least 3 months of community treatment are needed to produce significant improvement and reductions in recidivism and relapse. Because of the comparative stability of the prison population, several treatment options of differing intensities can be made available. The full range of services can be offered, including comprehensive assessment; treatment planning; placement; group, individual, family, and specialty group counseling; self-help groups; educational and vocational training; and planning for transition to the community. Therapeutic communities (TCs) are among the most successful in-prison treatment programs. They are highly structured, hierarchical, and intense interventions lasting a minimum of 6 months. TC participants live together, often separate from the general prison population, and take responsibility for their recovery process. Participants work at increasingly more responsible positions as they learn self-sufficiency and become competent.
Treatment for Offenders Under Community Supervision
Parolees and probationers are both under community supervision; nonetheless, they generally represent different ends of the criminal justice continuum. Whereas parolees are serving a term of conditional supervised release following a prison term, probationers are under community supervision instead of a jail or prison term. Both parolees and probationers generally can be controlled and managed effectively by a combination of treatment and surveillance while under community supervision at a far lower cost than incarceration in jail or prison. The level of supervision varies according to individual circumstances, including the terms under which probation or parole was granted. Offenders under community supervision in urban areas who have substance use disorders have available several levels treatment and supervision, including residential, outpatient, halfway, and day reporting centers. Parolees may have difficulty meeting their basic needs when they are released and benefit from case management services to help with housing and employment. Reunification with family members and social support may also prove problematic.
Relapse prevention is extremely important for those under community supervision. Relapse, which is not unusual, can be met by increased supervision and an intensification of the level of treatment. Likewise, the intensity of supervision and treatment should decrease as the individual meets treatment goals. For both parolees and probationers, reassessment should be periodically conducted throughout the phase of community supervision. Following their contact with the criminal justice system, both parolees and probationers benefit from continuing contact with the substance abuse treatment system as a means of reducing relapse and recidivism.
Key Issues Related to Program Development
Offender-clients will best be served by substance abuse treatment and criminal justice systems that are working together to help them in recovery and in becoming law-abiding citizens. This requires leaders in both systems who promote their mutual goals, endorsement for mutual goals from leaders, clarification of the goals, and recruitment of stakeholders in pursuit of the goals. The challenge for substance abuse treatment practitioners and criminal justice professionals is to work together to provide a coordinated response to ensure that offenders' needs are addressed while protecting public safety.
