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Center for Substance Abuse Treatment. Continuity of Offender Treatment for Substance Use Disorders from Institution to Community. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1998. (Treatment Improvement Protocol (TIP) Series, No. 30.)

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Continuity of Offender Treatment for Substance Use Disorders from Institution to Community.

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Chapter 2—Case Management and Accountability

Coordinating systems to help the newly released offender can seem overwhelming, due in large part to the burgeoning caseloads carried by public sector agencies. Not only are the criminal justice and substance use disorder treatment systems fragmented and sprawling, but the offender will likely need ancillary services as well (discussed in Chapter 5), which calls for case management. As discussed in Chapter 1, case management can follow an outreach, reach-in, or third-party approach, or some combination of the three. No matter what the model, research shows cost benefits, through reduced recidivism, of cross-system integration for offender transitional services (Inciardi, 1996; Abt Associates, 1995; Swartz et al., 1996).

Case management is the function that links the offender with appropriate resources, tracks progress, reports information to supervisors, and monitors conditions imposed by the supervising agency. These activities take place within the context of an ongoing relationship with the client. The goal of case management is continuity of treatment, which, for the offender in transition, can be defined as the ongoing assessment and identification of needs and the provision of treatment without gaps in services or supervision. Accountability is an important element of a transition plan, and case management includes coordinating the use of sanctions among the criminal justice, substance use disorder treatment, and possibly other systems.

Case Management in Transition Planning

Ideally, case management activities should begin in the institution before release and continue without interruption throughout the transition period and into the community. It is recommended that transition planning begin at least 90 days before release from jail or prison. Early initiation of transition planning is important because it establishes a long-term, consistent treatment process from institution to community that increases the likelihood of positive outcomes. The case manager's communication with other transition team members at an early stage supports all aspects of the offender's recovery and rehabilitation (e.g., education, health, vocational training).

Ideal Array of Services

Certain services are integral to a substance-using offender's successful transition to the community. Reassessments should be conducted at various stages throughout the incarceration and community release process. Similarly, offenders also need continued supervision after institution release. Continued supervision also includes ongoing monitoring and assessment of the offender's needs. These periodic substance use disorder and supervision assessments should form the basis for ongoing case management and service delivery. However, additional assistance is needed in a number of areas prior to and after release to prepare the offender for the return to family, employment, and the community.

Often the offender needs help finding housing, since family and social support networks and financial resources may be minimal. Other activities may include teaching basic life skills such as budgeting, using public transportation, seeking and maintaining employment, and parenting. Many offenders have a history of job instability, unemployment, or underemployment. Improving the clients' likelihood of obtaining a job through general equivalency diploma (GED) preparation, enrollment in an educational program, vocational training, or job-seeking skills class increases their chances of success after release.

Many offenders need training to enhance interpersonal skills in both family relationships and with peers. Training in anger management and in parenting groups can provide new methods for resolving conflicts and facilitating reintegration into the family and community. If possible, the family should be involved in case management and treatment services during the transition to the community. Participation in self-help groups is an important adjunct to substance use disorder treatment to engage the offender in the larger peer support community.

The array of services identified reflects the multiple psychosocial needs of offenders, and takes into account the likelihood that offenders will have periods of backsliding requiring more intensive levels of treatment and supervision.

An effective transition plan is dynamic and evolves as the offender accepts greater responsibility. The offender should be present at team meetings so that she can see accountability modeled as she participates with team members in implementing the plan in the community. Being a part of the planning process helps offenders begin to make their own decisions and take responsibility for themselves. Because of the clear system of sanctions and rewards, a sense of accountability is reinforced.

The Role of the Case Manager

Continuity of care implies that the range of services needed by offenders are received, regardless of the system. When the correctional system and the treatment system collaborate effectively, there is an increased likelihood of treatment success and a reduction in the risk of relapse and future criminal behavior.

Case management is a critical element underlying continuity of care. Studies indicate that case management improves shorter term outcomes of treatment for substance use disorders (Shwartz et al., 1997). The case manager(s) links the offender with necessary resources, tracks progress, reports information to supervisors, and monitors conditions imposed by the court. Systems differ widely in terms of which entity provides case management services, but the necessary functions are the same, whether this role is filled by one person, an interagency team, or a separate agency. The case manager works directly with the client and collaborates with other criminal justice and treatment provider representatives to ensure that the offender maintains abstinence and avoids reoffending.

Case management functions typically include the following activities:

  • Assessing an offender's needs and ability to remain substance- and crime-free
  • Planning for treatment services and other criminal justice obligations
  • Maintaining contact with the probation officer and other criminal justice officials
  • Brokering treatment and other services for the offender
  • Monitoring and reporting progress to other transition team members
  • Providing client support and helping the offender with all involved systems (i.e., treatment, criminal justice, and child welfare)
  • Monitoring urinalysis, breath analysis, or other chemical testing for substance use
  • Protecting the confidentiality of clients and treatment records consistent with Federal and State regulations regarding right to privacy (42 Code of Federal Regulations [C.F.R.], Part 2)

Staff members of the program Treatment Alternatives for Safe Communities (TASC) begin case management services for the offender as early as local jurisdictions permit -- pretrial, presentence, postadjudication, or prerelease (Weinman, 1992). In a model program in Hillsborough County, Florida, a TASC counselor is assigned to each offender and conducts an intake assessment for the community agency (Department of Justice, 1991). A plan used in Ohio calls for case management activities weeks or even months prior to release, to set the stage for successful reintegration in the community and to develop necessary linkages (Ohio Department of Alcohol and Drug Addiction Services and Ohio Department of Rehabilitation and Correction, 1997).

It is optimal to have a single, full-time case manager working in conjunction with a transition team of highly involved staff members from both systems. However, if the infrastructure and resources do not allow for a full-time case manager position, the primary counselor working with the offender should take the lead in providing these functions. In these cases, the Consensus Panel recommends that this role be filled by the treatment provider. As the provider has clinical and personal knowledge of the client, he can make appropriate referrals for ancillary services, such as employment, vocational training, medical treatment, and support for strengthening family relationships.

The increase in the use of the term boundary spanner to describe part of the function of a case manager underscores the fact that all organizations have boundaries. In social service systems, those lines are often unclear because of overlapping functions or gaps in functions. To avoid the fragmentation of care that often results from uncoordinated systems, the Consensus Panel recommends that a case manager or boundary spanner become the primary link between the offender and all necessary social services. The Panel recommends that the boundary spanner come from the community-based treatment program, or the supervising agency, though she may have a different "base" agency, depending on funding and other variables.

Ideally, the case manager assumes primary responsibility for identifying resources and helping the offender learn how to access them. The case manager's duties include clear, concise, and accurate documentation of the offender's progress, including development of transition plans, legal status, program protocols, and assessment results. This information should be shared with the treatment providers, supervising criminal justice agency, and other systems partners, as appropriate, who are collaborating on activities related to the offender's transition plan. The case manager needs a broad, in-depth knowledge of the programs, modalities, and services of the providers in the community to ensure an appropriate match for the offender.

Based on the assessment, the case manager should have the authority to make recommendations to the community supervision officer about the most appropriate treatment options. This is particularly true if there was originally a mismatch between the client's needs and the placement decision. It is important for the case manager to determine and document the reasons for transfer when the offender changes programs. Information on success and failure rates of placements can be useful when making future referrals.

The Concept of the "Boundary Spanner"

During site visits to jail mental health programs, one study noted that the most effective programs included a core staff position of boundary spanner. This person managed interactions among correctional, mental health, and judicial staff and enhanced the program regardless of the incarceration setting (Steadman, 1992). The boundary spanner interacted on a daily basis with representatives from all systems, and negotiated among these three (often competing) systems.

A boundary spanner is especially useful for offenders in transition to the community, and should be able to address different sets of legal, clinical, and social issues that arise at different points in the criminal justice system. Depending on the point in the system(s) where the offender is found, an entirely different set of legal, clinical, and social issues arise, and the boundary spanner should have the capacity to address them all.

Boundary spanners must manage the sometimes conflicting interests of many organizations. Therefore, those who perform this function should have an in-depth knowledge of the systems with which they interact, which may require some years of experience. Individuals who perform well in this role know both the formal and informal norms of the organizations, as well as their internal operations and politics (Steadman, 1992). Boundary spanners must be respected and have credibility from all the organizations with which they interact. In an ideal situation, the system supports the boundary spanner with a full-time position that pays a reasonable salary. The job title and pay should be based on the functions performed, rather than on professional degrees. It may be helpful to conceptualize the boundary spanner in the context of the provision of case management. Although many systems find difficulty in financially supporting such a role, the function of the boundary spanner is a useful model that may be adaptable in local jurisdictions.

Transition Plan Elements

Responsibility for continuity of treatment and offender accountability will be shared across systems. Below are elements that should be part of the transition plan.

Ongoing Comprehensive Assessments

The Consensus Panel recommends the development or identification and use of standardized, comprehensive risk and need assessment tools appropriate to offender populations. Offenders should be assessed as early as possible and throughout their involvement in the correctional system. Risk assessments done at the time of release help determine the appropriate level of supervision in the community (e.g., parole, postprison supervision). Needs assessments determine and document the offender's medical, psychiatric, psychosocial, and family circumstances, and help identify the appropriate level of treatment. Since the treatment needs of addicted offenders change over time, there is a need for periodic, updated risk and need assessments. Ideally, assessment information is part of a cumulative and automated assessment management system.

Multiple assessments of offenders with substance use disorders are necessary and should examine

  • Treatment Needs -- to determine what types of treatment interventions, services, and programs are appropriate
  • Treatment Readiness -- to evaluate the extent to which clients are motivated for treatment and whether they are likely to benefit from treatment
  • Treatment Planning -- to determine how intensive the treatment should be and on which areas it should focus
  • Treatment Progress -- to periodically determine whether clients are responding to treatment and whether treatment should be modified
  • Treatment Outcome -- to determine the extent of behavioral change, success, or failure (Inciardi, 1993)

Assessment for substance use disorders

Assessment for substance use disorders is central, since it helps determine the level of treatment services and type of treatment that can best meet the offender's needs. It may also help identify barriers to treatment.

Assessments should be standardized, following accepted clinical protocols such as the Substance Abuse Subtle Screening Inventory (SASSI), the placement criteria of the American Society of Addiction Medicine (ASAM), and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Since many factors associated with an offender's criminality will impact on his treatment needs, wherever possible relevant information from the risk assessment should be considered in evaluating the substance use disorder assessment. In New York State, the Division of Probation and Correctional Alternatives is working with the Office of Alcoholism and Substance Abuse Services to create a uniform assessment protocol for use across the criminal justice continuum, which addresses related risk elements in the substance use disorder assessment of the criminally involved client.

The substance use disorder assessment can be conducted by institutional treatment staff or by community program staff that comes into the institution or on site at the community program. Staff members conducting assessments should be clinically trained and meet the licensing or certification requirements of the jurisdiction. If an assessment is being conducted by a community-based treatment provider, it is vital that the offender's complete treatment records be made available to the treatment provider. The Consensus Panel recommends that assessments for inmates be conducted at entry to the institution and 3 to 6 months before release, at a minimum. Prerelease assessments increase opportunities for the offender to prepare for transition and allow institutional transition personnel and community providers to plan for the offender's entry into a program. Careful planning of assessments across points in the criminal justice system can help avoid duplication of effort and resources, preventing different parts of the system from unnecessarily repeating assessments.

While there are different models for conducting assessments of offenders in prisons, the process ideally is conducted through a multidisciplinary team approach. For example, in one approach, the institutional treatment staff provides a treatment summary and referral form for offenders who are in custody at a halfway house and participating in community-based treatment. In another approach, the community-based treatment provider conducts the assessment in the prison. Yet another approach has the offender, the corrections staff, the parole officer, and the community treatment provider all contributing assessment information.

Assessment of life skills

When offenders leave institutional treatment, they are often thrust into environments that feel utterly unfamiliar. Some say they feel like tourists in a culture they don't understand, with foreign rules and expectations. Offenders who have been in prison for several years may become disoriented and highly stressed and thus require counseling, while others may only need training in a few basic life skills. It is important for the case manager as well as the community treatment provider to understand the level of psychopathology that may be directly related to the duration of the incarceration.

Offenders often have significant needs for basic life skills such as managing the tasks of everyday living, responding to people who have biases about them, and coming to terms with societal norms and expectations. Case managers must ensure that these needs are met, since many offenders are easily frustrated. Therefore, assessments of offenders' overall skills for daily living should be conducted. For descriptions of various assessment methods, please refer to the TIP 27, Comprehensive Case Management for Substance Abuse Treatment (CSAT, 1998b).

The goals of assessments are to determine specific strengths and weaknesses and to locate opportunities for improvement in order to reduce the propensity for relapse. Critical areas to be assessed include stress management skills, general psychosocial skills, emotional readiness for the transition, and money management abilities. Other areas to assess are problem-solving abilities, decisionmaking, and other cognitive behavioral skills.

A case management assessment should include a review of the following functional areas. These items are not exhaustive, but demonstrate some of the major skill and service need areas that should be explored. The assessment of these areas of functioning gives evidence of the client's degree of impairment and barriers to the client's recovery. The case manager may have to perform many services on behalf of the client until skills can be mastered.

Personal living skills

The client's ability to perform basic self-care functions and to meet personal needs is a critical element in a case management assessment. Individuals with deficits in this area are most likely to have serious cognitive deficits and are also likely to have coexisting severe mental disorders or neurocognitive deficits secondary to trauma and/or substance use. The client should be assessed for ability to perform the following activities of daily living:

  • Personal hygiene and grooming
  • Management of sleep/wake cycles
  • Dressing, taking care of clothing
  • Preparing basic meals or obtaining a nutritious diet
  • Faithful and correct use of prescribed medications
  • Money management
  • Orientation and sensitivity to time

Social and interpersonal skills

Effective participation in the self-help groups often required of those with substance use disorders requires some level of social ability. The case management assessment should therefore include an evaluation of the client's

  • Conversational skills
  • Respect and concern for others
  • Appropriateness in varied social settings
  • Attachments, ability to form and sustain friendships and relationships
  • Constructive leisure and recreational activities
  • Anger and conflict management
  • Impulse management
  • Criminality and distorted thinking

Service procurement skills

While the focus of case management is to assist clients in accessing social services, the goal is for clients to learn how to obtain those services. The client should thus be assessed for

  • Ability to obtain and follow through on medical services
  • Ability to apply for benefits
  • Ability to obtain and maintain safe housing
  • Skill in using social service agencies
  • Skill in accessing mental health and substance use disorder treatment services

Prevocational and vocation-related skills

In order to reach the ultimate goal of self-supported independence, clients must also have vocational skills and should therefore be assessed for

  • Basic reading and writing skills
  • Skills in following instructions
  • Transportation skills
  • Manner of dealing with supervisors
  • Timeliness, punctuality
  • Telephone skills

The case management assessment should include at least a brief scan for indications of harm to self or others. The greater the deficits in social and interpersonal skills, the greater the likelihood of harm to self and/or others as well as endangerment from others. The case manager should also conduct an examination of criminal records. If the client is under the supervision of a criminal justice agency, supervision officers should be contacted to determine whether or not there is a potential for violent behavior, and to elicit support should a crisis erupt.

Assessment of literacy and employment

Assessment of literacy skills is another key component of the transition. Ideally, an offender who needs basic literacy training will have received it while incarcerated. Many institutions that have experienced funding reductions have successfully turned to local boards of education for funding or attracted volunteers to work with inmates. However, in many jurisdictions, the responsibility for literacy training has shifted to the community because of reduced funding for educational programs in prisons. Literacy training helps increase an offender's self-confidence in participating in society and dramatically increases the ability to seek and obtain employment. Offenders should receive training in other aspects of job readiness as well. They will likely need help with resume writing, interviewing techniques, and various reentry issues related to employment.

There are differences among States and systems with regard to employment following release. Sometimes offenders are required to begin work almost immediately (for example, within 2 weeks after release from prison). Absent such a requirement, however, an assessment of the relative priority of return to employment and treatment may determine that the latter is actually a higher priority. In such situations, the offender can address treatment needs while preparing for a return to employment. If the offender's emotional readiness to return to work is poor, the offender also can be provided with services (e.g., self-help and empowerment workshops, job readiness and skills training, mentoring).

Placement in an Appropriate Treatment Setting

Placement of the offender in a treatment program should be clinically appropriate and based on the results of risk and needs assessments. In an ideal transition, the offender participates in treatment planning and "buys in" to the program, internalizing accountability. Examples of appropriate treatment settings include a licensed residential treatment facility, a residential program with a licensed substance use disorder component, a licensed intensive outpatient substance use disorder program, a standard outpatient treatment program, a substance use disorder awareness and education program, and an aftercare program. Placement planning may also include linkages with and arrangements for participation in local self-help groups, including information on times and locations of meetings or obtaining a sponsor.

The placement should reflect the risk presented by the offender, that is, the level of responsibility and accountability that can be attributed to the offender. For example, a residential program provides a higher degree of accountability than an outpatient program. As an offender internalizes an accountability structure with the support of the treatment provider and the community supervision officer, he can be placed in a less controlled environment. Eventually, the community supervision officer may leave the transition team, and the offender may be supported only by the treatment provider. In some cases, however, community supervision may extend beyond the formalized treatment plan, and the offender will exit treatment and still be accountable to a legally mandated and enforceable period of supervision.

Relapse Prevention Plan

An individualized relapse prevention plan should be developed for each offender. This plan, which can be brief, generally lists the behavioral "early warning" signs that can be useful signals to all members of the transition team. It is often developed as a standard form, written in simple, nonclinical language, with a checklist of indicators that help predict the potential for relapse. Examples of effective relapse prevention plans and their components are reviewed in the CSAT publication, Relapse Prevention and the Substance-Abusing Criminal Offender (CSAT, 1993a).

According to Peters and Dolente, relapse prevention concepts are easily understood by inmates, who generally have the ability to learn why prior attempts to stop using drugs were unsuccessful and to anticipate situations that threaten recovery (Peters and Dolente, 1993). An effective relapse prevention plan involves self-help groups and peer support, as well as the community treatment and criminal justice systems.

Duration of Treatment

Since offenders with substance use disorders have a chronic, relapsing disorder, a treatment plan must be of appropriate intensity and duration. Findings of studies of the Amity Prison program in San Diego, the Key-Crest program in Delaware, and the Stay'N Out program in New York demonstrate that longer duration of treatment—of up to 1 year -- is consistently associated with better treatment outcomes among prison inmates (Lipton, 1995). The Amity program includes a 1-year residential aftercare component. The optimal duration for prison populations has typically been found to be 9-12 months. Recent findings of a Key-Crest study indicate that a longer and more comprehensive regimen of treatment increases the likelihood that an offender will be substance- and arrest-free in the long run (Inciardi et al., 1996). Findings from the Shwartz study previously cited, which describe outcomes from jail treatment to community treatment, indicate that outcome improves when the course of treatment is at least 30 to 90 days, followed by continuing community treatment. These results provide clear support for a comprehensive approach that includes jail or prison treatment followed by community aftercare for offenders with histories of substance use disorder problems.

Support Services

The psychosocial and substance use disorder assessments described above will help pinpoint offenders' needs for social services. Offenders may need help obtaining social services, especially in light of recent changes in welfare reform. They should receive, at the very least, up-to-date social resource and referral materials. Support services are discussed in greater detail in Chapter 5.

Depending on the capabilities of offenders, the case manager may need to be assertive in providing assistance, for example by helping offenders keep appointments, perhaps even by driving them to their appointment sites. However, the ultimate goal of treatment during the transition is to promote offender self-sufficiency. Though case managers may have to broker services initially, they should encourage self-sufficiency by having offenders secure services themselves.

Model Program: Women in Community Service (WICS)

WICS is a national nonprofit organization founded in 1964 in conjunction with the Job Corps. WICS consists of a consortium of women's groups that began a mentorship program which has evolved into a life skills program as well. Although not originally designed for offenders, the Shelby County (Memphis, Tennessee) Division of Corrections and the Oregon Department of Corrections have WICS programs for women inmates. These programs include a 10-week job readiness/life management program along with mentors from the community, many of whom are professionals or managers. In a recent outcome study, women offenders who participated in WICS were better able to find work and stay out of prison.

Transitional housing

Research demonstrates that extensive residential treatment following release or as an alternative to incarceration can reduce the rates of rearrest and relapse and increase the rate of employment (Martin et al., 1995; Hiller et al., 1996). This suggests that appropriate housing is an important aspect of positive treatment outcomes. A basic requirement for a successful transition is access to housing that is safe, free of substance use, provides a structured environment, and supports treatment goals. When offenders enter a residential treatment program, such as a therapeutic community, their housing needs and treatment needs will be met simultaneously. Another option for offenders is going to a halfway house and working in a furlough program.

Mentors and role models

Mentoring is an age-old practice that fosters growth and independence, often for the mentor as well as the person mentored. The case manager or specific service provider can develop and implement mentoring services to help promote successful reentry into the community. Currently used primarily with women and youth, mentoring services involve an individual outside the criminal justice system who provides personal support to the offender to help her access community resources and to provide social support. In this context, mentoring can help offenders raise their expectations and hone skills like problem solving and interacting with people.

In some mentoring programs, the mentors meet with offenders while they are still incarcerated and encourage them to set concrete goals, such as finding jobs, obtaining social services, and finding housing. Typically, the mentor is a nonprofessional who listens, provides support, and provides encouragement for life skills development.

Exoffenders who are no longer in the criminal justice system and have successfully navigated life in the community can become important role models in the lives of transitional offenders as volunteers. They can help by driving offenders to treatment, bringing them to social service appointments, helping them prepare for job interviews, sitting in on assessments with them, and accompanying them to 12-Step meetings and peer support group meetings. Both staff members and volunteers can serve as role models. The Fortune Society in New York City, for example, provides counseling, education, alternatives to incarceration, career development, substance use disorder treatment, AIDS/HIV counseling, education, and referrals to offenders. The counselors at the Fortune Society are exoffenders or recovering substance users and serve as role models, tutors, teachers, and therapists. (See Chapter 6 for more on this program.)

Self-help groups

In addition to developing other role model concepts in treatment programming, transitional programs can encourage interaction with 12-Step programs, Rational Recovery, Project Smart, Winner's Circle, and other self-help programs. In self-help groups, sponsors generally mentor newer members.

When offenders participate in self-help programs such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) during incarceration, they learn to talk openly about substance-use-related challenges and successes in an emotionally safe environment. These self-help meetings take place throughout the country and are often connected with community treatment programs. As a result, offenders who participate in self-help groups in institutions have a ready-made and familiar source of support in the community. When members of the 12-Step community go to institutions and run 12-Step meetings, they provide personal linkages to the community and to other 12-Step groups in the community.

Participation in 12-Step groups provides peer support for remaining abstinent, handling daily living problems, and developing a healthy social network. In addition, the self-help approaches and methods work well in combination with treatment: 12-Step milestones can be used as treatment objectives; educational sessions can incorporate the 12 Steps, and 12-Step philosophies can be incorporated into the overall treatment process. At the Interventions-Wilmer program, for example, the eighth step, "making amends," is incorporated into the final 3 months of treatment (Barthwell et al., 1995). Institution and community programs can support the 12-Step process by providing the space for AA and NA meetings on site. Under the Bridging the Gap Program in New York City, inmates receive and send letters to AA members in the community. Weeks before release, they are given the times and locations of AA meetings in their home community, and may even be met and taken to their first AA meeting on the day of release.

In addition to 12-Step programs, other self-help groups can contribute to successful transitions. Winner's Community is a developing national network of successfully recovering exoffenders. This program has created a prosocial community among graduates of therapeutic community (TC) and other substance use disorder treatment programs.

Winner's Community, which encourages honesty, a work ethic, personal accountability, economic self-reliance, caring/concern for others, family responsibility, community involvement, and good citizenship, operates both in the institution and in the community (De Leon, 1995). The therapeutic peer support network in the community is called Winner's Circle; members engage in frequent community meetings and activities. Winner Circle is the institution-based meeting for offenders participating in drug treatment in prisons and jails, preparing offenders for the challenges on the outside when they are released. This gives transitioning offenders a ready support network upon release.

Family involvement

Many offenders do not have intact or available families, and many offenders' families pose a risk for substance use or recidivism. Nevertheless, if they can provide positive support for the goals of the treatment, family members should be involved in the assessment, planning, and treatment of transitioning offenders.

Ideally, family education efforts should occur before the release of the offender. Significant others and family members should receive information about what to expect when the offender makes the transition to the community. They should also understand the nature of the treatment program in the incarcerated setting, the substance use disorder, the transition plan, and resources for the offender and the family. If appropriate, family members may be asked to provide collateral information about the offender's situation, but offenders should always be asked if they want their families involved in their treatment and give formal consent.

If assessment and treatment planning meetings are conducted in residential treatment or halfway houses, family members can sometimes participate in meetings and meet with parole officers. Some prisons permit family members to participate in prison-based meetings prior to the offenders' release. In fact, some prisons allow extra family visits contingent on the family's willingness to participate in treatment meetings.

To be a positive support for the offender and to participate in the reintegration process, family members may benefit from social and self-help resources, such as Al-Anon and Toughlove groups. Another support group is Prison Families Anonymous, for families with members who have been involved in the corrections system. This valuable resource can address such issues as guilt, responsibility, owning one's behavior, detachment, and control. This group also has a referral service to help families locate other resources.

Model Program: Providence House

Providence House in New York is a sanctuary of six transitional homes committed to providing drug-free shelter and support to homeless, abused, and formerly incarcerated women and their children in a hospitable, compassionate, and communal atmosphere. Volunteers who work outside the houses live permanently in the houses, creating a core community, providing stability and supervision. In addition, trained staff members provide case management within the homes.

Fostering Accountability

Offender accountability is demonstrated by responsible behavior that helps an offender build a crime-free and substance-free lifestyle. It includes the fulfillment of commitments to legal authorities, to the substance use disorder treatment plan, the community, and to oneself. Accountability develops when an offender internalizes the structure learned within a program and applies it to life after incarceration—following rules, adapting to a work culture, and adopting community norms. When an offender demonstrates the need for fewer external controls on his behavior and less supervision, he is rewarded with more life choices and greater freedom.

Four interlocking components can help ensure offender accountability and continuity of care during transition from incarceration to the community. They are criminal justice supervision, sanctions for violations, rewards for progress, and treatment with ancillary services.

Model Program: WomenCare, Inc

WomenCare, Inc., is a private not-for-profit mentoring program in New York City that recruits and trains volunteer mentors to help women released from prison adjust to life outside. Mentors receive ongoing training emphasizing problem-solving techniques and skills to enable the offender to take personal responsibility and make independent life decisions. Three months before an offender's discharge, a mentor begins visiting the incarcerated woman to formulate realistic goals and mutual expectations. On the day of the discharge, the mentor is waiting for the offender to help her make the initial transition to the community. The mentor can offer moral support and concrete help. WomenCare has a working relationship with more than 80 service providers assisting in areas dealing with housing, employment, treatment, health, parenting, legal assistance, and education.

Community Supervision

Offenders with substance use disorders should have some form of community supervision stipulated upon release to help maintain treatment progress. However, some States cannot stipulate the continuation of treatment upon release. In the State of California, for example, an offender has a right to challenge parole recommendations and reject substance use disorder counseling, even if recommended by a transition team or parole officer. In most cases, however, mandated treatment supports the work of the transition team by lending the authority of law.

The Use of Incentives and Sanctions

The use of incentives and sanctions is an integral part of community supervision, although sanctions are generally less powerful than incentives in changing behavior (Gendreau, 1996). However, sanctions are often essential in fostering accountability in offenders.

Sanctions, or responses to noncompliant offender behaviors, help hold offenders accountable and protect public safety. Offenders should be told exactly which sanctions will be used in response to particular noncompliant behaviors at orientation. Sanctions are most effective when applied in a graduated or "tourniquet" manner. Appropriate sanctions include either punitive or supervision-oriented responses (such as increased urine testing) as well as therapeutic responses (such as increased treatment level). Effective sanctions are matched to specific behaviors by severity. For instance, the first missed appointment should not result in a return to prison, but a fourth "dirty urine" calls for more than a verbal warning. Finally, the parties responsible for services to the offender should be involved in applying sanctions. In other words, sanctions are most effective when applied by a team approach.

Innovative and creative sanctions should be developed to address violations. The methods used should be understood and agreed upon in advance by both substance use disorder treatment and community supervision staff. Sanctions should be swift and certain or the credibility of the system and accountability are greatly reduced. On the other hand, the sanction system should include a mechanism to lessen the intensity of requirements for those making measurable progress in both the legal and treatment requirements.

Examples of sanctions typically provided by the criminal justice and the treatment agencies are shown in Figure 2-3.

Periodic Reviews of the Offender's Progress

The transition team should conduct periodic reviews of the issues addressed by the transition plan, including legal requirements, appropriate placement in a level of care, the effectiveness of sanctions, and the extent to which the offender is meeting expectations. Risk and needs assessments can help determine the level of supervision required.

During periodic assessments, supervisors should look at concrete measures of accountability, such as a progress report detailing treatment attendance and progress, and patterns of relapse and urinalysis results. A protocol should be established to make urinalysis an accountability tool that can be used randomly, for cause, and by program design throughout the transition period. A baseline urine test should be administered on the first visit to the criminal justice authority after release. The results can then be used as a measure against subsequent tests.

Violations of any aspect of the transition plan must be dealt with consistently, appropriately, and in a timely manner. A lax attitude will jeopardize the individual offender's accountability, as well as public safety and the integrity of the program. In some cases, the decision must be made for offenders to return to prison or jail. The case management team must continually balance the conflicting needs of flexibility through individualized treatment planning with the consistency needed for personal accountability, treatment integrity, and public safety.

Discharge and Safety Issues

Treatment discharge must be planned with community safety as a central issue, and criminal justice discharge procedures are determined by law. However, criminal justice and treatment staff can work closely together on discharge and related issues until termination of supervision. A discharge team should include someone from the releasing institution, a community supervision officer, a treatment provider, and, if available, the case manager. The treatment discharge summary is completed by the treatment provider.

Treatment staff receives information on compliance from criminal justice staff who, in turn, is informed of treatment progress. If the offender commits a technical violation after discharge, supervision may be extended, even if the infraction is not substance related. Any behavior issue is also considered a treatment issue. Depending on the type of discharge required by law or recommended by the treatment provider, an offender should always be made aware that treatment is available.

The length of stay in the program should be determined by the treatment provider who, along with the community supervision officer, can monitor the progress of the offender. In some cases, the treatment phase may end, but a criminal justice agency maintains supervision authority over the offender. In those cases, if a treatment reinoculation is needed, the mechanism for it should be built into the system.

States should consider developing jail and prison diversion programs as graduated and intermediate sanctions for technical violators so that the offender can move from community-based treatment back to short-term services, maintaining continuity of care. A complementary system of incentives can also help prevent violations by rewarding and encouraging accomplishments and achievements. Programs of this nature can help decrease criminal activity, ensure continuation of treatment, and prevent relapse. For example, the Stay'N Out program at the Arthur Kill Correctional Facility at Staten Island, New York, has a special relapse prevention program. The Amity Program at the Richard J. Donovan Facility uses a 30-day "dry-out" prison program as an intermediate sanction. The Willard Drug Treatment Campus in New York State provides parole violators with an opportunity to enter a 90-day corrections-based treatment program without returning to jail or prison.

The Transition Planning Process

Successful transition from criminal justice institutions to community treatment is almost always the result of purposeful and careful planning. This planning must take place at both the State level and institution level for prisons, as well as the many agencies and programs involved in the transition. Coordinating information exchange and training will produce a more efficient and efficacious planning process. This transition or follow up planning is required by the various standards of correctional health care. In the National Commission on Correctional Health Care standards, for example, the issues are addressed under a separate continuity of care section.

The Flow of Information

The transition team should clarify the sources of information necessary for the transition plan. For example, interagency and intersystem agreements should be clearly defined early in the planning process so that roles, responsibilities, and policies can be clarified; confidentiality issues can be addressed; and means of covering treatment costs can be identified. Once confidentiality issues are addressed, data maintained in management information systems (MIS) can be shared to promote interagency communication, increasing the likelihood of successful transitions. An MIS can provide rapid access to information across agency lines.

The transition plan for an individual should increase the quality of information transferred from staff in the institution to providers in the community, decreasing problems caused by miscommunication about the offender between the community supervision officer and treatment staff.

Cross-Training

Parole officers, institution treatment providers, community treatment providers, and corrections release counselors should be cross-trained to improve appropriateness of placements. Cross-training builds trust and reduces conflicts between staff members from different systems.

Immersion training may also be an appropriate intervention that ensures better referrals and that fosters a systemwide understanding of the offender. The goal of immersion training is to provide an intense educational experience for all system representatives (judicial, corrections, probation, parole, clinicians, and other community representatives) about the transition process. The Texas Commission on Alcohol and Drug Abuse and the Texas Department of Criminal Justice provide immersion training to familiarize system representatives with their Criminal Justice Treatment Initiative, which provides different levels of treatment to inmates, parolees, and probationers. The Texas training is a 3-day session that includes role-playing and other interactive exercises to help increase the sensitivity of various players toward the offender's problems, obstacles, and challenges in transition from prison to the community.

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