Treatment During Incarceration

Some incarcerated offenders enter treatment for the same reasons as those "on the outside": They want to stop using substances and need help. Others, however, may have different motivations: boredom, the desire to improve their chances for parole, a wish to escape the violent culture of general population, or some combination of the above. Others may be mandated to treatment by the courts. Surprisingly, research shows that once an offender begins treatment, outcomes are not affected by the reasons for entering treatment (Leukefeld and Tims, 1988). A certain proportion of those who undergo treatment within the institution will succeed if supervised closely (Anglin and McGlothlin, 1984; Petersilia et al., 1992). Other key findings on the effectiveness of substance use disorder treatment within correctional institutions include the following:

• Prerelease therapeutic communities have shown high rates of success among inmates studied (Wexler et al., 1988; Field, 1989).
• Involvement in substance use disorder treatment is associated with decreased criminal recidivism. Improvements have been seen in rates of rearrest, conviction, reincarceration, and time to recidivate (Field, 1995a; Inciardi, 1996; Peters et al., 1993; Swartz et al., 1996; Wexler et al., 1990).
• Involvement in substance use disorder treatment is associated with decreased substance use and relapse and other health-related outcomes (Inciardi, 1996; Martin et al., 1995; Wexler et al., 1990).
• Duration of correctional substance use disorder treatment is associated with positive treatment outcomes. Research has shown that, up to a point, longer lengths of treatment are more effective than shorter lengths of treatment for substance-using offenders (Swartz et al., 1996; Wexler et al., 1992).
• Involvement in substance use disorder treatment, such as prison-based therapeutic communities, is associated with successful parole outcomes (including reductions in parole revocations) (Field, 1989; Wexler et al., 1992).
• Inmates involved in substance use disorder treatment had reduced rates of re-arrest and relapse when compared with inmates who did not participate (Federal Bureau of Prisons, 1998).

Treatment During Transition To the Community

Service systems should provide offenders with appropriate treatment, since no treatment is likely to lead to continued drug use and crime. Treatment that stops when the offender is released, however, may not be enough. Release presents offenders with a difficult transition from the structured environment of the prison or jail: Despite the hardships endured "inside," they at least knew what to expect. Many offenders are released with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to access available resources for adjustment to life on the outside, all factors that significantly increase the risk of relapse and recidivism (Leshner, 1997). The positive effects of substance use disorder treatment within correctional institutions may diminish once the offender moves out of the institutional environment unless followup care is provided in the community (Martin et al., 1995; Peters et al., 1992; ; Swartz et al., 1996).

The benefits of treatment during the transition from incarceration to the community are substantiated in several recent studies. In a study of drug offenders in Delaware, offenders who participated in 12 to 15 months of treatment in prison and another 6 months of treatment in the community were more than twice as likely to be drug-free 18 months after release as those who had only the prison treatment. Those offenders were also arrested much less in the year and a half following release (Inciardi, 1996). A similar study in California had comparable results (Wexler, 1996). Continuity of care from the institution to the community is associated with positive outcomes for prevention of relapse and criminal recidivism in other research as well (Swartz et al., 1996; Wexler et al., 1990).

A demonstration program in the Oregon Department of Corrections reduced re-arrest rates and conviction rates among inmates participating in a transition program (Field and Karecki, 1992). This program emphasized transition from the institution and treatment in the community, rather than providing intensive treatment within prisons and jails, along with a postrelease aftercare program.

Lack of System Coordination

The criminal justice system is not a discrete, well-coordinated system, but rather a cluster of independent agencies and entities with separate justice responsibilities. Of those entities—law enforcement agencies, bonding authorities, jails, pretrial release agencies, courts, probation agencies, community-based service providers, prisons, and parole agencies -- some may collaborate closely, while others function independently. Most operate under separate funding streams, with differing organizational missions that may or may not share philosophical orientations toward public safety and offender rehabilitation.

An offender's tour through the criminal justice system may include encountering the police when she is arrested, spending time in jail before or during trial, being reviewed for treatment needs by the court before or after sentencing, being diverted from prison to probation, having probation revoked and being sent to prison, and then being placed on parole following a prison sentence. Each step may involve a different agency. The Criminal Justice Treatment Planning Chart (Center for Substance Abuse Treatment [CSAT], 1993) provides a detailed guide to both treatment intervention opportunities and places where an offender could fall between the cracks within the typical criminal justice system.

This fragmentation inhibits transfer of information about the offender and results in duplication of some services, such as assessment, and a gap in the continuity of other services, such as case management and treatment service delivery. In many jurisdictions, institutional programming is run by an executive agency, while probation may be part of the courts. Even when all correctional interventions are part of the same administrative agency, the gaps between institutional and non-institutional services can be significant. Legal issues, particularly confidentiality, may keep information out of some transition team members' hands.

Unfortunately, the gaps in information lead to a lack of accountability for the offender upon release or transfer. Both the criminal justice and treatment systems need as much information as possible about an individual in order to ensure continuity of care; each should take advantage of the increased technical capabilities for automated information systems.

As the number of substance-using offenders escalates, and the health and social service systems that must be accessed upon release become increasingly complex, interagency linkages between correctional, health, and substance use disorder treatment systems are critical. Staff from all systems should look for opportunities to advocate for clients by brokering among different systems, facilitating immediate treatment based on periodic assessments, and learning methods for system collaboration.

Lack of Attention to Offender Issues by the Community Service System

The criminal justice population contains many who need substance use disorder treatment, yet within most community programs few specialized staff are assigned to meet offenders' needs. This is in part due to the fact that State and local substance use disorder treatment agencies have not always identified offenders as a priority population, and those agencies that provide community supervision do not always fund treatment services during probation or parole. Though offenders remain an underserved population, national, State, and local efforts have improved community treatment responsiveness to offender populations during recent years.

Another problem area may be that program licensing and State credentialing standards do not take into account the needs of the offender population. Although recently, a criminal justice treatment professional certification process was developed by the Certification Board for Addiction Professionals of Florida and the International Certification and Reciprocity Consortium. Counselors sometimes provide treatment services without appropriate supervision or monitoring. One obstacle to effective treatment may be the policy of some programs to restrict the hiring of exoffenders as treatment counselors. Such staff members can improve a program, because they may relate more readily to the needs of these clients than those whose background differs substantially from the population served.

Funding Complications

As with most systems relying on funding from the public sector, both criminal justice and substance use disorder systems experience financial difficulties due to disconnected funding streams and competition for limited funds. Offenders making the transition from the correctional system to substance use disorder treatment in the community face an additional obstacle, in that they need services from both systems yet may not fit readily into either funding category. Available dollars are earmarked for either institutional or community services, but not for coordination between the two. Funding streams typically flow to specific divisions of social service agencies and are available only for a narrowly defined population. Prison services are usually State-funded, while community services are often county-funded. Some funding sources, including Medicaid, cease when the recipient enters prison. Ironically, funding available from some Federal agencies is not used because the population defined as needing it cannot get access in the current system.

Managed care organizations are increasingly involved in treatment decisions and may not agree with the community treatment plans for the offender. Managed care representatives may regard institution treatment as sufficient or assume that an offender who has been abstinent throughout incarceration does not need treatment. Managed care decisionmakers also may simply opt for a lower level of care than is deemed necessary by corrections or local treatment staff. New York requires managed care organizations (MCOs) to cover court-ordered offenders who may not meet the "medical necessity" criteria of the MCO. New York is currently the only State with such a law, even though many in the justice system consider public safety a more relevant treatment criterion than medical necessity.

The lack of funding for institutional programs is particularly problematic in small, rural jails and in some State prison systems. For example, a nationwide survey found that only 9 percent of small jails (fewer than 50 beds) had a funded substance use disorder treatment program, as compared to 60 percent of jails with more than 2,000 beds (Peters et al., 1992). Nor is there enough funding to create the capacity for needed community and institutional services, or for special populations such as women, women with children, and offenders with mental illness. Services are sometimes discontinued as offenders are released from jail or prison because there is no case manager to advocate for the offender. Offenders are put on waiting lists or do not receive appropriate treatment. This in turn leads to poor retention in treatment and negative outcomes (e.g., relapse or recidivism).

Typically, the only treatment services that are reimbursable in the community involve direct contact with the client, such as individual counseling, group therapy, and assessments. This is true whether the funding entity is a single State agency, a managed care plan, or Medicaid. However, what will be paid for is not necessarily what clients need. Those services for which community treatment programs are reimbursed, and areas that are the focus of performance evaluations, are not necessarily the services needed by offenders making a transition from institutional settings. For example, a significant amount of time must be spent interacting with various agencies to create linkages on behalf of the offender, yet such case management services often are not reimbursable.

Funds are rarely targeted specifically for transitional services, although innovative programs are being conducted now in Texas, Delaware, Oregon, California, and New York. The Federal prison system included a transition component in its 1989 program design, and Congress has funded this national transitional effort. Clear articulation of the public safety benefits of specific transition services helped the Federal system obtain this funding. Some jurisdictions are beginning to capitalize on the investment made in institutional treatment by supporting specific community-based services to promote continued or ongoing recovery.

For example, since August 1996, the New York State Division of Parole has channeled funding to the State Office of Alcoholism and Substance Abuse for contracts with local treatment agencies which agree to admit offenders on a priority basis. Under the agreement, the agencies also provide enhanced case management services to people released from the Willard Drug Treatment Campus (DTC). Willard DTC is a State-run, 850-bed, licensed treatment facility for substance-using, nonviolent felons. Payments to providers are performance-based.

Coordination of Sentencing and Treatment

Whenever possible, treatment should be structured to fit within the sentence imposed by the court and, conversely, sentences should be structured to accommodate the treatment needs of the offender. The latter requirement can take several forms: Sentences can be structured so that assessments are ordered, and the defendant must follow the recommendations for treatment. In some jurisdictions, the court will modify a sentence to accommodate treatment participation after the initial imposition.

The legal system is structured to determine guilt or innocence and the primary emphasis of the court is on public safety—typical presentence and probation reports focus on risk to the community and the legal issues surrounding the defendant. Although courts have no legal obligation to attend to the substance use disorder treatment needs of offenders, some have recently taken a proactive role, recognizing that addressing substance use disorders can reduce further criminal activity and enhance public safety. The proliferation of treatment drug courts, offender-dedicated treatment programming, and alternative sentencing that includes treatment are examples of this trend.

For such programs to work, judges must be given the information they need to mandate treatment participation, particularly the need for and availability of treatment. Prior to any treatment mandate, the court should receive the results of a thorough substance use disorder assessment of the offender, performed by a qualified professional. Mandating treatment without such a qualified assessment may be seen (understandably) as retribution or punishment. Judges will also need clinical guidance in order to shape the appropriate and specific treatment interventions. Inappropriate placement in a jail or prison program, therapeutic community, or community treatment program can contribute to dropout, lack of service provision, or wasted resources. Judges also need to follow through with swift and certain sanctions for offender noncompliance.

With the advent of new criminal justice initiatives such as the Treatment Alternatives to Incarceration Program in Texas, judges can obtain more information to make treatment recommendations in their sentences.

Judges can play a critical role in the treatment of offenders by crafting sentences that enable or require treatment participation, by responding when there is a crisis or change in circumstances that requires additional treatment or supervision interventions, and by making appropriate accommodations when the offender meets treatment goals. Such judicial oversight is featured in various treatment drug courts and programs, such as CSAT's Juvenile/Criminal Justice Treatment Networks, Birmingham's Breaking-the-Cycle, and Treatment Alternatives for Safe Communities (TASC). In treatment drug court programs, supervision, treatment, and case management services are linked to the court, with individual oversight of each offender provided by a judge. Depending on the jurisdiction, offenders participate in these programs in lieu of or as part of a criminal sentence. In treatment drug courts, judges hold special "status hearings" to monitor the progress of offenders in treatment throughout their stay in the program.

In New York, the Brooklyn District Attorney's office took a leadership role in 1990 by beginning a program called Drug Treatment Alternative to Prison for defendants facing mandatory prison sentences, thus giving the prosecutors and judiciary a mechanism to sentence prison-bound nonviolent drug offenders to residential treatment, usually a therapeutic community. The program has been experiencing about a 70 percent retention rate in treatment since its inception. Six counties in New York State are now using this model. TASC is also used in some of these counties to assess, refer, and case manage.

Offenders are significantly more likely to continue in treatment after release if they are placed under community supervision (Hubbard et al., 1989) with conditions specifying involvement in treatment. While transition planning benefits all offenders, it is particularly important to offenders who need substance use disorder treatment.

Recommendations for Overcoming Obstacles

Institution Outreach

In this model, a member of the institution's staff initiates linkages with agencies and services beyond the institution. Among the services that require coordination are community substance use disorder treatment and other social services, parole or postprison supervision, and work release programs.

Community Reach-In

Under this model, community programs assume primary responsibility for initiating treatment and transitional services before the offender's release. Staff members from the community agency "reach in" to the institution and begin the process of preparing the offender for transition and establishing necessary linkages.

Third-Party Coordination

Third-party coordination can be a program model or a method of contracting for brokering and coordination of some or all services. It may be used with either of the models previously described (or a hybrid model that includes elements of both). When a third party is used, some coordination and case management functions are not performed by either the treatment provider or the individual responsible for supervision. Rather, an independent agency or program (such as TASC; see box below) serves as a liaison and is responsible for identifying transitional service needs, coordinating (not delivering) services, and matching offenders with these services. The third party may be from either the public or private sector. It may be particularly useful to broker for services in this way in more complex systems. Third-party models are more likely to be helpful in coordinating large systems, including multiple programs and services.

An Integrated Transition Approach

Although each program model has its strengths, transition planning ideally involves both institution and community services in a "mixed model." Such an integrated approach provides opportunities for effective collaboration and more readily unites systems because they are forming an alliance to reach mutual goals. The systems gain a greater understanding of each other, learn a common terminology, and develop trust in each other's work.

When systems integrate their functions to provide transitional services, there is enhanced preparation for those offenders who are being released from jail. Critical service needs are more easily identified, and the offender has a better opportunity to become engaged in community treatment. Relapse prevention efforts are more likely to succeed.

Additionally, the mixed model allows systems to be more responsive to critical incidents, because monitoring and surveillance are more coordinated, there is better communication across systems, and sanctions are developed and enforced by both the criminal justice and substance use disorder treatment agencies.