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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.)
Continuity of Offender Treatment for Substance Use Disorders from Institution to Community.
Show detailsIt is well documented that the most effective substance use disorder treatment is multifaceted and addresses many aspects of the substance user's life. This is particularly true for criminal justice populations, yet treatment providers generally do not match offenders with substance use disorders to services tailored to their needs. Effective care for those with mental and physical health problems, for example, must incorporate the care of these illnesses into the plan for treatment of substance use disorders and criminality. Assessment and treatment efforts must also acknowledge and incorporate the offenders' differences in culture, gender, age, and type of criminal offense.
People with mental and physical health problems constitute a major category of special needs populations. Society's failure to provide appropriate options for them contributes to disproportionately high numbers of these individuals who eventually find themselves under criminal justice supervision -- and many of these offenders, particularly the mentally ill, cycle through the criminal justice and social services systems repeatedly because their problems are not fully addressed in any system. For example, once individuals with mental illness are incarcerated, short-term goals of controlling undesirable behavior and a reliance on medication often take precedence over more comprehensive approaches to treatment.
Upon release, offenders with multiple problems suffer from an additional stigma and may be denied services because community providers lack training to deal with their problems. For example, providers who do not understand the issues for those with mental illness or mental retardation may believe that these individuals cannot benefit from treatment and are dangerous. Part of the case manager's job is to add to the transition team those specialists who can correct such misinformation.
However a population is defined (e.g., by a health problem or cultural background), it is important to know the substances of choice, types of crime, and other life patterns. Elderly people, for example, abuse prescription drugs and alcohol, but rarely use illicit drugs. People with mental retardation are often arrested for nuisance offenses and may be manipulated into criminal activities. Women's substance use is often woven into their intimate relationships; many are incarcerated for possession of a drug that their significant others are selling. These substance use patterns have significant implications for treatment.
Cultural sensitivity and cultural competency, important in all treatment, are particularly essential with offender populations, because minorities are notoriously overrepresented in incarcerated settings. For example, 40.5 percent of the prison population is African-American (Department of Justice, 1998), even though African Americans make up only 12.7 percent of the general U.S. population according to September 1998 census data (U.S. Census Bureau, 1998). For some offenders, such as those of African-American and Latino heritage, the family and extended family should be specifically included in the transition plan because of the importance those cultures place on family relationships. Self-help models of treatment may need adaptation for different cultures and for women.
Ideally, staffing patterns at all levels of the treatment system should reflect the population served, from clerical staff through executive management. Specific efforts should be made to recruit and maintain such staff members. Licensing, certification, and credentialing should support the use of culturally competent staff, and support continuing education in the knowledge and skills relevant to the population. Staff members should be able to communicate in local languages and dialects, and published materials and consent forms should be available in these languages as well. If this is not possible, staff members should find creative means to compensate for this deficit, although family members, especially children, should never be used as interpreters. Incentives that encourage culturally sensitive client interactions should be woven into the employee performance evaluation system.
Whether the differences are cultural, medical, age-, or gender-related, it is important to remember that offenders are not a homogenous population. This chapter will help community treatment providers and correctional workers deliver effective transitional services to groups with special needs.
Women
In 1997, slightly less than 8 percent of those incarcerated were women—6.4 percent of the prison population and 10.6 percent of the jail population (Bureau of Justice Statistics, 1998), but that percentage is rising. Women are substantially more likely than men to serve time for a drug offense rather than a violent crime.
Compared to men, women are more heavily drug-involved (Drug Use Forecasting, 1997), and are often polydrug and intravenous drug users, though they use less alcohol than men. Women in prisons in 1996 were most likely to be black (46 percent), ages 25-34 (50 percent), unemployed at the time of arrest (53 percent), and never married (45 percent). In State prisons in 1991 more than 75 percent of the women had children; two-thirds had children under the age of 18 (Bureau of Justice Statistics, 1994).
Incarcerated women and women with substance use disorders are more likely to have suffered physical and sexual abuse (Hein and Scheier, 1996; Miller et al., 1993; CSAT, 1998a). Incarcerated women's physical health profiles include a high incidence of HIV/AIDS and other STDs, pregnancy, and certain types of coexisting mental disorders. The most common mental health disorder among female offenders is depression. At the Turning Point Alcohol and Drug Program for women in Oregon, approximately 50 percent were diagnosed with depression (Edens et al., 1997) (see box). Another commonly found disorder is post traumatic stress disorder, not uncommon in victims of physical and sexual abuse. The importance of addressing women's health care in correctional settings is spelled out by the National Commission on Correctional Health Care's (NCCHC) position statement on Women's Health Care in Correctional Settings. In it, NCCHC recommends, among other things, intake procedures that include gynecologic history and nutritional intake, pregnancy tests, tests for STDs, and available counseling for depression, substance use disorders, and other disorders common to incarcerated women (National Commission on Correctional Health Care, 1994).
Until recent years, substance use disorder treatment programs for women have been slow to emerge in correctional institutions and in the community, and many institutions still have no women-specific treatment services. Those services that are available often evolved from models developed for men.
Incarceration disrupts relationships with children, as well as with a spouse or partner. If a woman is a single parent involved in drugs and criminal behavior, a child protective service agency generally steps in after the arrest to take control and custody of dependent children. A high percentage of mothers have their children permanently removed from their custody as a result of their incarceration. Parental rights for mothers (perceived as chief caretakers) are scrutinized closely by social services and foster care workers. In some jurisdictions, women have been increasingly criminalized for using drugs when pregnant.
Model Program: The Turning Point Alcohol and Drug Program
The Turning Point Alcohol and Drug Program at the Columbia River Correctional Institution in Oregon is a 50-bed therapeutic community for women housed in a minimum security State prison. Originally designed to provide only substance use disorder treatment, high program dropout rates due to mental health problems led to the integration of mental health services. About 60 percent of the women in the program are dually diagnosed. Of those, approximately 70 percent have been diagnosed with post traumatic stress disorder, 50 percent with depression, and 15 percent with bipolar disorder.
Transition Issues
When the transition is made to the outside, problems that were temporarily left behind must again be confronted. Domestic violence was a reality for many female offenders before they were incarcerated, and may well be a risk for them when they return to the community. Probation reports may fail to identify this problem, and substance use disorder staff may not be sensitized to it. Case managers should explore this issue as a critical part of the transition plan, and alert community treatment providers. If an offender has no safe place to go, she can be directed to a women's shelter. Some women may resist going to a shelter, because they fear that their children will be taken from them if they do so. Many shelters accept children, however, and a safe environment is of primary importance.
Women may lack social support for spending time on their treatment needs. Drug-involved significant others can pose a significant barrier to a woman's recovery. Making time for treatment sometimes means putting one's own needs first, which can be difficult if a partner opposes the change, or if a woman is the primary caregiver or supporter responsible for minor children. Economic self-sufficiency is a challenge for those who have never held a traditional job or developed employment skills, especially for those faced with supporting their children and themselves. Educational opportunities and job training may differ in men's and women's facilities; it is essential that women are given an adequate chance to prepare themselves for the return to the community.
Transition Services Needed
As with other populations, women should have an effective and realistic transition plan based on a comprehensive biopsychosocial assessment. The plan should consider obstacles, including child care, economic responsibilities for children, and current or prior abuse that are relevant to women and that could preclude or inhibit successful participation in treatment. When possible, women should be referred to programs designed specifically for women. If this is not available, providers should be encouraged to develop same-sex programming. Case managers and counselors should receive training around women's issues and strategies for working effectively with women. Women need positive role models in treatment, both male and female.
As women have distinct medical needs, it is important to address gynecological and reproductive health issues and to provide HIV/AIDS education and services. Women with depression can be linked with women-specific group programs that use medication in combination with cognitive-behavioral treatment. There are also other specialized mental health groups for women offered both in the institution and on the outside.
Because women so often have principal child care responsibilities, and because those responsibilities can be overwhelming, it is important to help women meet their family obligations as they return to the community. Parenting classes can be of help and quality child care may be essential for some women to make a successful transition.
For many women who have not had their children returned to them upon release, family reunification is an important goal. Case management is essential when dealing with a wide variety of issues and public agencies; legal advocates can be of great help in facilitating this process. Special programs may ease the transition. Hour Children, based in Queens, New York, is an agency providing assistance for mothers and children both before and after release. It has advocates for children who transport a child who is in placement to visit the parent or will intervene on behalf of the mother to assist with parental rights issues.
Women may need more job readiness training and job-seeking assistance than men, because many incarcerated women have little or no legitimate work experience. Before they return to the community, it is important that they be given as much preparation as possible. Although assertiveness training generally addresses a wide range of life situations, it can be of particular help preparing women for job-related challenges.
Peer support for substance-using offenders often includes 12-Step programs. Specialized 12-Step groups exist for women, but some controversy exists regarding the appropriateness of traditional 12-Step groups for this population. Some criticize the requirement that women submit to a "higher power" as disempowering to women, who may need to be more assertive, not less. Kasl has developed an alternative 16-step program for women that downplays Alcoholic Anonymous' concept of powerlessness (Kasl, 1992). Kasl replaced the concept of surrendering with one that emphasizes accepting, affirming, and trusting oneself. The support offered by 12-Step self-help groups, especially those designed specifically for women, can be essential to women during transition and recovery (Covington, 1994).
The Institutional Substance Use Disorder Program Discharge Summary, included in Appendix B, is an example of a discharge plan used with incarcerated women in some jurisdictions. It is completed in the last 3-6 months of the sentence and asks questions concerning personal goals in many domains of life. The counseling staff guides the offender as she thinks through issues surrounding abstinence, social plans, and physical and recreational goals. The form also includes space to develop a relapse prevention plan. After release, the parole or probation officer receives the completed form to help with transitional treatment goals. The summary plan is a very useful tool, but only if it is shared by the members of the transition team.
Elderly Offenders
Elderly people are now found in correctional institutions in greater numbers because of mandatory minimum sentencing and longer sentences. These prisoners have more health problems and long-term medical conditions than their younger counterparts. The stress of return to the community can be much greater for elderly offenders, especially if they have been incarcerated for many years and have no family or familiar sources of support. See TIP 26, Substance Abuse Among Older Adults (CSAT, 1998a) for more on elder-specific substance use disorder treatment.
Transitional Issues
Older people have more chronic health issues and less family and peer support. In addition, they may need help accessing a variety of services and entitlement programs—Medicare, Social Security, or perhaps veterans' benefits. The geriatric population is more likely to need supported living arrangements, such as nursing homes. Time management may be more of an issue than among younger people, in part because the elderly are less likely to be employed. The transition team should include an expert in medication management.
Offenders With Mental Illness
Studies indicate that coexisting substance use disorders and mental health disorders occur in approximately 3 to 11 percent of the prison and jail population (Peters and Hills, 1993). Jails have particularly high rates of coexisting disorders. In 1995, urinalysis at booking indicated that more than half of all arrestees tested positive for illicit drug use; 5 percent had both a substance use disorder and a mental illness (National GAINS Center, 1997). Incarcerated substance users have an especially high rate of serious mental illness, as approximately 26 percent have a lifetime history of major depression, bipolar disorders, or schizophrenia (Cote and Hodgins, 1990).
Often, correctional facilities merely stabilize acute conditions or may even overmedicate to control behavioral difficulties. People with mental illness are especially vulnerable to victimization within the corrections system, and often there is little family involvement or other outside support. The coexistence of a substance use disorder and mental illness presents a diagnostic challenge, as substance use disorders can mimic or mask underlying psychiatric conditions. Additionally, these inmates are often reluctant to disclose their substance use history. A recent cross-training curriculum instructs staff in both systems on working with offenders with coexisting mental health disorders (Virginia Addiction Technology Transfer Center, 1996). (See Figure 6-1 for a review of treatment programs for this population).
Transition Issues
Professionals in the corrections or treatment communities sometimes have negative preconceptions about this population. It is difficult for those with coexisting disorders to get parole, because parole board members often have little understanding of these disorders or of current treatment methods, and they are primarily concerned about community safety when considering release. Sometimes inmates refuse medication before an appearance before the parole board so they can truthfully say they are not being psychiatrically medicated.
Transition Services
For many offenders who are mentally ill, maintaining a stable mental health status requires careful monitoring and coordination. An important initial step to support the offender in transition is to verify that medicines and files are transferred. Consistency in treatment and medication is critical, but failures in continuity are common. Neglect of medications and treatment can lead to a downward spiral toward relapse. In some cases, offenders are overmedicated at the time of release to the community, because high doses of medication reduce disciplinary problems in the institution. The transition team, especially the community provider, may be left to deal with issues of disruption in medication or of over-medication.
Case managers should take an active role in ensuring intersystem communication, as the mental health and substance use disorder systems are sometimes separate in prison and usually separate in the community as well. Some substance use programs in the community refuse to treat the mentally ill, while some mental health facilities turn away those with substance use disorder problems. Such actions violate the Americans With Disabilities Act, which prohibits substance use disorder programs from turning away people with other disabilities and social service programs from refusing people with substance use disorder problems. Philosophical approaches to treatment -- for example, medical model versus self-help model -- may divide providers and interfere with treatment. All parties treating this group of offenders should come to agreement on a treatment approach and common terminology. Mistrust of the other system and exclusionary policies should be addressed and minimized.
Lack of insurance (or underinsurance) creates the potential for discontinuity of treatment following placement in the community. Corrections agencies may discontinue mental health services once the offender is released. Every effort must be made to identify funding for mental health treatment. Greater duration and intensity of treatment improves outcomes, but may run counter to current managed care strategies of reducing length of treatment. In the current environment of managed care, advocacy for this population is essential.
Services necessary for a successful transition for those with coexisting disorders also include
- Assertive outreach by the case manager to engage the offender in services
- Comprehensive assessments of both substance use disorders and other mental disorders followed by treatment plans designed to monitor and continue to identify these disorders
- Tracking through the criminal justice system and into the community
- Cross-training of substance use disorder and mental health staff and community correction/security staff about both types of disorders
- A transition plan that takes into account mental illness as well as substance use in relapse prevention efforts
- A sufficient supply of medication and careful medication planning that is coordinated among the offender and staff from all systems (i.e., criminal justice, mental health, substance use disorder)
- The provision of structured daily activities, as those with mental illness may need that structure
- Practical help with everyday tasks -- such as filling out forms to guarantee eligibility for Federal programs (e.g., Medicaid, Social Security disability benefits)
- Preparation of offenders for involvement in 12-Step groups, as many self-help groups won't accept those on medication (specialty groups such as Double Trouble that offer support to those with coexisting disorders should be sought)
- Substance use disorder and mental health treatment that is provided by a multidisciplinary staff
Offenders With Mental Retardation
The term "mental retardation" describes developmental disabilities that range from moderate to very severe. In prisons, most inmates who are mentally retarded have compromised intellectual functioning but are not profoundly retarded. Individuals with more severe disabilities are usually housed in specialized State facilities separate from the criminal justice population. Those with borderline IQs often are not eligible for services from State mental retardation agencies and end up in the criminal justice system.
A key issue for the mentally retarded in incarcerated settings is their vulnerability. Correctional officers may unwittingly give such inmates directives they don't understand and berate the inmate for disobeying. Because inmates with mental retardation may have poor judgment, they are easily exploited or manipulated by other inmates. For example, they are often used in drug trafficking -- and more likely to be caught -- because of their naivete.
Transition Services Needed
An assessment of intellectual level should be provided by the correctional facility prior to the offender's return to the community. It is important to have experts in mental retardation involved in the transition. Qualified individuals who can participate in the transition team can often be found in area schools that receive funding for special education. Advocacy groups that promote the interests of persons with mental retardation can also be of substantial help. Finally, high functioning exoffenders with mental retardation can perform a valuable mentoring role.
Illiteracy is an issue for many offenders with mental retardation, and treatment efforts must be geared toward the appropriate level of comprehension. Help may be needed in basic areas such as dressing appropriately, maintaining proper hygiene, planning nutritious meals, and completing paperwork and forms that will be required in the community.
Additional research and training curricula for treatment and criminal justice staff are needed on the best methods for managing and treating individuals with both substance use disorders and mental retardation. One helpful curriculum was developed at the State University of New York at Buffalo (Posluszny et al., 1996).
Sex Offenders
Because sex offenders have often served long sentences, they may experience significant difficulties during transition because of the impact of institutionalization.
Treatment aimed at diminishing the impulse to commit sex offenses generally does not also incorporate comprehensive substance use disorder treatment components for sex offenders with substance use disorder histories. Sex offenders are often barred from substance use disorder treatment both while incarcerated and in the community. When they do receive treatment, it is common for sex offenders to overreport their substance use so they can claim that their sex offenses were caused by problems with substances. They may want to enroll in treatment programs to impress a parole board rather than out of a genuine desire for abstinence.
Generally, it is useful to address the sex offender's behavior prior to focusing on substance use issues. However, treatment must take into account both problems. As the relationship between substance use disorder and violent offenses is complex, it is important that the treatment providers who work with this population have a sophisticated understanding of the issues. As many States are now eliminating programs for sex offenders, the substance use disorder treatment community may become the first line of treatment for many of these individuals, which highlights the field's need for an in-depth understanding of this population.
Long-Term Medical Conditions
Inmates often have chronic and contagious medical conditions, so it is crucial to prevent prisons from becoming incubators for disease. The fact that there can be long periods before a disease is diagnosed makes the spread of disease more likely. Implementing universal precautions against blood contamination is in the interest of public health. Given the high numbers of intravenous drug users in the criminal justice population, and the occurrence of unprotected sex in prisons, the risk of spreading HIV is substantial. Adding to that risk, inmates who are aware that they are HIV-positive may not want to disclose this information. Tuberculosis, other airborne diseases, and hepatitis also flourish in the institutional setting. Hepatitis C, which is becoming more common, is not currently treatable with antibiotics.
Health services accreditation programs such as that offered by the National Commission on Correctional Health Care (NCCHC) disseminate standards that address these concerns. In facilities that meet those standards, the health services program functions as a "public health department" for a prison community.
Women often have long-term health problems, and many have engaged in prostitution or other risky behaviors. Female prisoners' rate of infection with HIV has been increasing. This trend may reduce access to general substance use disorder programs, either because the infectious condition is used to exclude these individuals, or because their medical needs cannot be met within the substance use disorder treatment program.
In addition to preventing the acquisition of new health problems in prison, it is necessary to ensure that preexisting conditions are adequately treated. For example, those with HIV should be treated with an appropriate drug regimen to prevent full-blown AIDS from developing. Prisoners needing dialysis or other medical services must have access to competent and sufficiently frequent care.
Transition Services Needed
If offenders have had their medical needs addressed in prison, it will help facilitate a smooth transition back to the community. It is critical that there are no gaps in treatment or the receipt of medications. The treatment schedule established in the institution should continue on the outside without interruption.
Medical problems can be potent relapse triggers, and depression can lead to renewed substance use disorders. Resumption of substance use can harm the immune system, aggravating physical problems. Community providers should be aware of the mental health risks associated with particular diseases and work to forestall difficulties.
The Panel recommends the mainstreaming of those with HIV into community treatment groups. HIV and other support groups within the community, however, can enhance the effectiveness of substance use disorder treatment. TIP 15, Treatment for HIV-Infected Alcohol and Other Drug Abusers, describes the linkages and social service needs for those with substance use disorder problems and HIV (CSAT, 1995). Legal issues, such as confidentiality considerations, are also discussed in detail in TIP 15, which will be revised in 1999.
Offenders With Physical Disabilities
Physical disabilities take many forms. Some impede mobility; others limit sensory or expressive capacity. The Americans With Disabilities Act (ADA), 42 U.S.C; Chapter 126, requires that State and some private facilities be accessible and that programs accommodate those with disabilities. Section 504 of the Rehabilitation Act of 1973, 29 U.S.C., Chapter 16, governs all Federal programs and facilities. Reasonable efforts must be made to enhance or modify substance use disorder treatment. Solutions go beyond merely removing architectural barriers. For example, blind prisoners can be given treatment materials either in Braille or on tape. Sign language interpreters may be necessary for hearing impaired prisoners. Thoughtful logistical planning is imperative in meeting the needs of this population.
Transition Services Needed
A balance must be struck between providing special services for offenders with physical disorders and mainstreaming. Sometimes special units will be necessary; in other instances, minor modifications can allow these individuals to participate in programs with the general population.
A screening for disabilities, including traumatic brain injury or certain physical conditions, should be conducted at intake into the correctional system. When the offender returns to the community, all relevant medical information should be transmitted to the appropriate parties. If medication is used to treat the disability, it is important that there is no gap in its use.
Many advocacy groups safeguard and promote the interests of disabled persons. During the transition period, contact with representatives of these groups may be helpful. For more information on this topic, see TIP 29, Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities (CSAT, 1998).
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