Title : QGCover tip17 9-05-01ph.qxd (Page 2) Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 17 Planning for Alcohol and Other Drug Abuse Treatment For Adults in the Criminal Justice System ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . . 2 What is a TIP? . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 The Substance-Involved Offender . . . . . . . . 8 The Criminal Justice Continuum . . . . . . . . 12 Collaboration Between Systems . . . . . . . . 16 Staff Issues . . . . . . . . . . . . . . . . . . . . . . . . 19 Confidentiality Issues . . . . . . . . . . . . . . . . . 20 Relapse and Recidivism . . . . . . . . . . . . . . 24 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based almost entirely on information con tained in TIP 17, published in 1995 and based on information updated through approximately 1993. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 17 Planning for Alcohol And Other Drug Abuse Treatment for Adults In The Criminal Justice System ----------------------------------------------- 2 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System WHY A QUICK GUIDE? This Quick Guide was developed to accompany Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System, Number 17 in the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. This Quick Guide is based entirely on TIP 17 and is designed to meet the needs of the busy clinician for concise, easily accessed "how-to" information. The Guide is divided into eight sections (see Contents) to help readers quickly locate relevant material. Terms related to these treatment methods are list ed on page 26 in the Glossary. These terms are included to enable clinicians to talk knowledge ably with their clients and clients' medical providers. For more information on the topics in this Quick Guide, readers are referred to TIP 17. ----------------------------------------------- What Is a TIP? 3 WHAT IS A TIP? The TIP series has been in production since 1991. This series provides the substance abuse treat ment and related fields with consensus-based, field-reviewed guidelines on substance abuse treatment topics of vital current interest. TIP 17, Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System • Addresses concerns of a broad range of readers including clinicians, social workers, medical per sonnel, mental health workers, program admin istrators, and policymakers • Includes extensive research • Is a comprehensive reference for clinicians in substance abuse treatment. See the inside back cover for information on how to order TIPs and other related products. ----------------------------------------------- 4 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System INTRODUCTION Research has shown that criminal offenders have higher levels of substance use than nonoffenders. In addition, they tend to have higher rates of sub stance use before becoming involved in the crimi nal justice system. Studies have also linked increased substance abuse with a greater likeli hood of committing an offense. In turn, evidence has been consistent in demon strating that alcohol and drug abuse treatment not only reduces substance use, but also reduces criminal activity. The purpose of TIP 17 and this quick guide is to forge and strengthen the links between the crimi nal justice and substance abuse treatment sys tems. This is done through increased respect and understanding between personnel in the two sys tems and jointly defined purposes and objectives. Key Principles The effort to control substance abuse can bring the justice and substance abuse systems in closer proximity to each other. While many view the end of one system's responsibility as the beginning of the other's, professionals in both systems now have a better understanding of the repetitive, cir cular nature of the interactions among the justice ----------------------------------------------- Introduction 5 system, the substance abuse treatment system, and the community. The benefits derived from cooperation between the criminal justice system and substance abuse treatment system can flow both ways. Substance abuse treatment for offenders helps the criminal justice system reduce recidivism and gives alter natives to incarceration (when appropriate). Treatment within prisons and jails may improve inmate behavior problems. Neither substance abuse treatment nor criminal justice efforts alone are sufficient to deal effectively with substance- involved offenders. Here are several key points to form a framework for developing recommendations to promote the reduction of substance abuse: • Substance abusers are not a homogeneous group. • Treatment works. • A single treatment program or approach will not be successful for all offenders. • Incarceration alone usually does little to change behavior. • People without a stake in society may view anti social behavior as a way to maintain a sense of power. ----------------------------------------------- 6 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System • Long-term reduction of drug use is dependent on changes in society's attitudes about both drug use and the justice system's role in preven tion. System Differences The criminal justice and substance abuse treat ment systems work from different incentives, val ues, training, and standards, but they share com mon goals for the benefit of society: the reduction of deviant behavior and the reduction of sub stance use and associated criminal activity. • Criminal Justice System—exists to protect pub lic safety with a focus on laws, procedures, and processes designed to incapacitate and punish individuals who threaten the lives and well- being of others. The Scope of the Problem The number of drug-abusing offenders has signifi cantly increased with many cycling in and out of the justice system and accounting for a large pro portion of crime. It is fair to assume that treatment intervention will have a major impact on reducing crime, but it is important that the criminal justice and substance abuse treatment systems work well together to achieve this outcome. ----------------------------------------------- Introduction 7 • Substance Abuse Treatment System—has a responsibility to address the great harm that substance abuse and dependence exact on individuals, their families and friends, and the organizations and communities in which they interact. It often provides support and under standing to facilitate individual change. For more detailed information, see TIP 17, pp. 1–3; 40–41. ----------------------------------------------- 8 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System THE SUBSTANCE-INVOLVED OFFENDER Substance-involved offenders are not a homoge neous group. Differences are found, even among those people of the same age and gender who have the same cultural, ethnic, social, and eco nomic backgrounds. Differences include personal ity, patterns of substance abuse, health status, socialization, education, family, job training, urban and rural influences, and mental functioning. Very often, their only shared characteristics include involvement with alcohol and illicit drugs and the criminal justice system. Some factors to consider when working with sub stance-involved offenders Culture and Ethnicity Many offenders are young male members of cul tural and ethnic minority groups with low educa tional attainment. Treatment providers need to demonstrate cultural competency skills in dealing with clients of various minority groups. Women Women primarily enter the justice system when apprehended for nonviolent criminal activity aris ing from economic motives. Most women who are incarcerated are low-income, single heads of households with dependent children. Most are ----------------------------------------------- The Substance-Involved Offender 9 unemployed prior to incarceration and a large por tion come from families in which there is a pattern of incarceration over generations. HIV/AIDS The elevated rate of HIV infection among incarcer ated individuals is largely attributed to needle sharing between injection drug users. HIV must be addressed at every level of the criminal justice system. Successful HIV prevention in the prison population is dependant on personnel education and training. Tuberculosis Because TB is transmitted through the air, prisons and jails are high-risk settings for the spread of infection. While improvements in prevention and treatment of TB lowered the prevalence rates for decades, in recent years the challenge of TB has risen due to the appearance of multidrug-resistant TB. Co-existing Mental Illness This segment of the offender population is not often appropriately served. A significant number of addicted offenders have lifetime histories of depression, bipolar disorder, atypical bipolar disor der, and schizophrenia. They need access to coor dinated mental health services. ----------------------------------------------- 10 Keep in mind... The first 24 hours after release can be especially critical, and there must be a system in place to ensure that an individual released from incarcera tion gets into a treatment program. Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System Transition From Institution to Community It is important to recognize the need for offenders to make a smooth transition into the community, a process that involves identifying and addressing special needs before the offender's release from the institution. At the end of the period of incar ceration, recommendations about community- based treatment programs should be incorporated into parole plans. For more information about the transition from institution to community, see TIP 30, Continuity of Offender Treatment for Substance Use Disorders From Institution to Community. Sexual Abuse and Violence Many substance-involved offenders are perpetra tors of violent behavior and many more are vic tims, which can interfere with substance abuse treatment. Supportive counseling can address issues of violence, anger and impulse control, and a history of physical or sexual abuse. ----------------------------------------------- The Substance-Involved Offender 11 By understanding the variations among offenders, the criminal justice and substance abuse treat ment systems will be better prepared to address the increasingly limited resources and the rising number of individuals entering the justice system. For more detailed information, see TIP 17, pp. 17–23; 43–44. ----------------------------------------------- 12 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System THE CRIMINAL JUSTICE CONTINUUM To provide the most effective services, substance abuse treatment providers must work within each phase of the criminal justice system. They must have an understanding of the case-flow process at every stage and maintain communication with all those involved. Stages in the Justice Continuum: Arrest and Pretrial Arrest can be a significant event in a person's life because it may make it difficult for him to deny substance abuse problems and offers him the opportunity to enter treatment. Coerced Treatment: For and Against Several studies indicate that clients who enter sub stance abuse treatment because they are forced to do so by the criminal justice system make as much progress as those who enter treatment vol untarily. However, some researchers are opposed to coerced treatment on philosophical or constitu tional grounds, and there are clinicians who believe there is little benefit to forced treatment. Connections must be made between the treat ment and criminal justice systems at the point of arrest. ----------------------------------------------- The Criminal Justice Continuum 13 Pretrial information about a defendant can be grouped into the following categories: • Criminal record • Prior compliance with supervision • Pretrial evaluation • Substance abuse assessment information • Substance abuse treatment information Arraignment and Plea Bargaining There is an open window of opportunity to discuss the need for substance abuse treatment with the individual during the period between arrest and arraignment. During the arraignment, charges are brought against the defendant and he is informed of his rights. The defendant enters a plea in response. Due to court overcrowding, defendants have a greater chance of plea bargaining to reduce the charges against them. A sentence requiring the defendant to enter treatment can be part of the plea bargain, and many systems have been suc cessful in getting individuals into a program at this point. Presentencing Presentencing is the period after a guilty plea is entered (in cases that are plea bargained) or after ----------------------------------------------- 14 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System a conviction is handed down (in cases that go to trial). Based on a presentencing investigation, the judge hands down a penalty based on the infor mation compiled in the presentence report. Both the substance abuse treatment and the criminal justice systems must be linked at this point to provide the defendant with a substance abuse intake and preliminary assessment. The information gathered at this point may be highly relevant to developing a treatment plan for the individual. Trial A trial is a court hearing in which a prosecutor presents a case against the defendant to show he is guilty with a judge or jury deciding a verdict. Increasingly, States are passing laws to ensure that the penalty is based on the offense without regard to information contained in the presen tence investigation report. Sentencing Sentencing is the imposition of penalties on the defendant, usually with the use of the presentenc ing report. The goals of sentencing are to reduce community risk and punish the offender fairly while rehabilitating him. ----------------------------------------------- The Criminal Justice Continuum 15 Probation Probation is a sentence of community-based supervision and includes stipulations and prohibi tions on certain activities as well as fines imposed by the court. Its effectiveness is measured by a reduction in the offender's criminal activity and his ability to perform productively in the communi ty after completing probation. For more detailed information, see TIP 17, pp. 25–29; Appendix B. ----------------------------------------------- 16 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System COLLABORATION BETWEEN SYSTEMS Conditions for Effective Relationships Across Systems The following principles and examples apply to the criminal justice and substance abuse systems: • Members are concerned about their own group's or system's effectiveness. • Members have confidence in their own group or system. • Members believe in the interdependence of the other system and their system. • Members are willing to accept or develop a superordinate goal to link the systems. • Members are willing to interact with other groups in other systems in coordinated joint ventures. Ongoing Issues The criminal justice system imposes sanctions for a certain period of time, while the substance abuse treatment system works with a client for an indeterminate length of time until he can achieve and maintain sobriety. The challenge is to look for creative ways to apply sanctions and provide incentives for offenders to continue treatment after their involvement with the criminal justice system. ----------------------------------------------- Collaboration Between Systems 17 Recommendations Specific suggestions for State action plans include • Identify shared populations and determine top priorities common to both systems. • Require cross-training for substance abuse treatment, criminal justice, and public health staff. • Develop and refine management information systems relevant to all three systems. • Develop a system of waived offender informa tion available to all three systems (substance abuse treatment, criminal justice, and public health). • Develop loose-leaf resource manuals so that new material and changes that are relevant to both substance abuse treatment and criminal justice systems can easily be added. • Publicize successful examples of improved offender rehabilitation resulting from effective linkages between the substance abuse treat ment and the criminal justice systems. • Involve the media in publicizing issues and spe cific examples of substance abuse treatment and criminal justice linkages. • Encourage linkages with State, local, and pri vate resources to maximize efficiency and effec- ----------------------------------------------- 18 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System tiveness in substance abuse treatment pro gramming. • Encourage case management as an important linkage activity. • Involve the community. • Investigate possibilities for federally funded pilot projects that encourage and support the crimi nal justice, substance abuse treatment, and public health systems to work together collabo ratively. For more detailed information, see TIP 17, pp. 56; 65–66. ----------------------------------------------- Staff Issues 19 STAFF ISSUES Burnout People who work with substance abusers in the criminal justice system experience high levels of stress, especially those who work directly with clients. To better handle a burnout, staff should • Recognize the signs of burnout in oneself and others • Understand how the burnout affects significant others • Incorporate the role of peer support in prevent ing and dealing with burnout • Know the importance of institutional policy and response to staff burnout Client Violence If a client becomes abusive, staff should be prepared to handle the situation through proper training in • The formation of groups within the institution to address the aftereffect of violent incidents, especially stress syndromes such as posttrau matic stress disorder • How to de-escalate or otherwise respond to potentially violent situations • Stress management strategies, including relax ation techniques For more detailed information, see TIP 17, p. 72. ----------------------------------------------- 20 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System CONFIDENTIALITY ISSUES The General Rule Federal confidentiality laws and regulations pro tect any information about an offender if the offender has applied for or received any sub stance abuse-related services from a program that is covered by the law. The rule applies from the time the offender makes an appointment with the treatment program. It is for those mandated into treatment, those who go on a voluntary basis, and also former clients or patients. Consent Most disclosures are permissible if an offender has signed a valid consent form that has not expired or been revoked. Consent forms must be signed voluntarily; the offender is free to choose not to receive treatment. A proper consent form must be in writing and must contain each of the following: • The name or general description of the pro gram(s) making the disclosure • The name or title of the individual or organiza tion that will receive the disclosure • The name of the patient who is the subject of the disclosure ----------------------------------------------- Confidentiality Issues 21 Information protected by the Federal confidentiality regulations may always be disclosed after the offender has signed a proper consent form. The most commonly used exception to the general rule prohibiting disclosures is for a program to obtain the offender's consent. • The purpose or need for the disclosure • How much and what kind of information will be disclosed • A statement that the patient may revoke the consent at any time, except to the extent that the program has already acted on it • The date, event, or condition upon which the consent expires, if not previously revoked • The signature of the patient • The date on which the consent is signed A general medical release form, or any consent form that does not contain all of the above ele ments, is not acceptable. Special Rules About Consent Forms Some special rules apply to consent forms when an offender comes for assessment or treatment as an official condition of probation, sentencing, dismissal of charges, release from detention, or ----------------------------------------------- 22 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System other disposition of any criminal proceeding. The consent form is still required, but the rules con cerning the length of time the consent remains valid are different. The regulations require the fol lowing factors be considered in determining how long a criminal justice system consent will remain in effect: • The anticipated duration of treatment • The type of criminal proceeding in which the offender is involved • The need for treatment information in dealing with the proceeding • When the final disposition will occur • Other information the patient, program, or crimi nal justice agency believes is relevant These rules allow programs to continue to use a traditional expiration condition for a consent form when there is a substantial change in the patient's justice system status. The rule to follow: Keep in mind the purpose of the communication and disclose only what is nec essary, for only as long as is necessary. ----------------------------------------------- Confidentiality Issues 23 If you didn't already know. The results of urine tests performed by substance abuse programs are protected by Federal regula tions. However, testing conducted by criminal jus tice authorities or correctional facilities for the purpose of uncovering illegal drug use or monitor ing offenders' (or inmates') compliance with rules against illegal drug use are not protected under the Federal regulations. and.... Only offenders who have "applied for or received" services from a program are protected. If an offender has not yet been assessed or counseled by a program and has not himself sought help from the program, the program is free to discuss the offender's drug or alcohol problems with oth ers. But from the time the offender applies for services, or the program first conducts an assess ment or begins to counsel the offender, Federal regulations govern. For more detailed information, see TIP 17, pp. 72–78; 88. ----------------------------------------------- 24 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System RELAPSE AND RECIDIVISM Relapse and Recidivism: What's the Difference? Relapse is not clinically regarded as a treatment failure, but as an indication that the treatment plan should be changed to address the cause or circumstances associated with the relapse. Treatment success can be measured by a reduc tion in the relapse rate when compared with the relapse rate of an untreated group or a group that received a different treatment. Recidivism has been defined as "an offense com mitted by a person who has previously been con victed or adjudicated for an offense" and focuses more on the client's behavior rather than his ten dencies. If evaluators decide to rely on official records as the measure of recidivism, they must decide which level of contact with the criminal justice system will be used to determine recidivism. Should the measure of recidivism be rearrest, reconviction, reincarceration, or technical violations of probation or parole? ----------------------------------------------- Relapse and Recidivsm 25 Outcome Measures A variety of measures have been used to assess the effectiveness and treatment outcomes for substance-involved offenders. These outcome measures include changes in • Criminal activity • Vocational skills • Institutional adjustment • Family relationships The specific measures selected should include behaviors specified in program goals and objec tives. The treatment program designed to reduce substance use, decrease criminal involvement, improve self-concept, and increase job skills must include an evaluation designed to collect data on each of these variables. Regardless of the positive benefits the programs may produce, criminal justice drug treatment pro grams that are unable to bring about significant reductions in drug use and recidivism cannot be regarded as effective. Thus, measures that focus on relapse and recidivism are commonly used as indicators of program effectiveness in criminal jus tice settings. For more detailed information, see TIP 17, pp. 93–95. ----------------------------------------------- 26 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System Glossary Assessment: Evaluation or appraisal of a candi date's suitability for substance abuse treatment and placement in a specific treatment modality/setting. Community reintegration planning: Preparation and strategy for each individual prisoner's release from custody. Developmental interagency coordination: Collaboration among criminal justice personnel, treatment personnel, and public health personnel to form expert justice/treatment/public health systems. Drug testing: Technical examination of urine sam ples to determine the presence or absence of specified drugs or their metabolized traces. Intermediate sanctions: Community-based pro gram providing increased surveillance, tighter con trols on movement, more intense treatment for a wider assortment of maladies or deficiencies, increased offender accountability, and greater emphasis on payments to victims and/or correc tions authorities. Pre-release assessment: Infectious diseases risk assessment recommended for all potential parolees. ----------------------------------------------- Glossary 27 Pre-sentence hearing: Event at which the prose cutor, defense attorney, and judge meet prior to a trial to establish parameters for the trial. Pre-trial hearing: Appearance in court before a magistrate at which bond is set or a determination is made to retain in jail or release. Relapse prevention: Strategy to train substance abusers to cope more effectively and to overcome the stressors/triggers in their environments that may lead them back into drug use. Treatment: Any intervention that may change behavior. Trial/Sentencing: Court hearing at which a prose cutor presents a case against the defendant to show that he or she is guilty of a crime; the judge or jury decides the verdict. Unbroken contact: Early, thorough, and substan tial substance abuse treatment delivered in an unbroken manner throughout the entire criminal case-handling process, from arrest through the completion of the sentence. For more detailed information, see TIP 17 Appendix B, CSAT Criminal Justice Treatment Planning Chart. ----------------------------------------------- 28 Planning for Alcohol and Other Drug Abuse Treatment for Adults In The Criminal Justice System ----------------------------------------------- Ordering Information TIP 17 Planning for Alcohol and Other Drug Abuse Treatment For Adults in the Criminal Justice System TIP 17-Related Products KAP Keys for Clinicians based on TIP 17 Quick Guide for Administrators based on TIP 17 Do not reproduce or distribute this publication for a fee without spe cific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT's Website at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: See the inside back cover for ordering information for all TIPs and related products. DHHS Publication No. (SMA) 01-3568 Printed 2001 TIP 7, Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System (1994) BKD 138 TIP 12, Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System (1994) BKD144 TIP 21, Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System (1995) BKD169 TIP 23, Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing (1996) BKD205 TIP 30, Continuity of Offender Treatment for Substance Use Disorders (1998) BKD304