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Substance Abuse Treatment: For Adults in the Criminal Justice System [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 44.)
In This Chapter….
While many similarities exist between substance abuse treatment for those in the criminal justice system and for those in the general population, people in the criminal justice system have added stressors, including but not limited to their precarious legal situation. Criminal justice clients also tend to have characteristics that affect treatment. These include criminal thinking and criminal values along with the more typical resistance and denial issues found in other substance abuse treatment populations.
Many offenders also have a long history of psychosocial problems that have contributed to their substance abuse: interpersonal difficulties with family members, difficulties in sustaining long-term relationships, emotional and psychological problems and disorders, difficulty managing anger and stress, lack of education and vocational skills, and problems finding and maintaining gainful employment (Belenko and Peugh 1998; Peters 1993). These chronic problems often are associated with reduced self-esteem, anxiety, depression, and enhanced expectations about the initial use of substances. Unsuccessful attempts at abstinence also tend to reinforce a negative self-image and increase the likelihood that offenders will use substances when faced with conflict or stress.
This chapter addresses strategies for modifying substance abuse treatment services for criminal justice clients. Some of these strategies are underlying program components, such as incentives for program participation and emphasis on personal accountability; others are more directly related to clinical issues, such as intervening with criminal thinking and teaching basic problemsolving skills.
While the suggestions offered here are applicable to many criminal justice clients, it is important to note that treatment approaches must take into account the unique situation of the offender and his stage in the recovery process. Treatment plans and assessments should be continually revised to reflect changes in the client's situation, such as recent relapses, continued sobriety, and improvements in mental and psychological functioning. For more on issues affecting specific subpopulations within the criminal justice system, see Chapter 6.
Substance abuse counselors working with criminal justice clients are likely to face a host of challenges. Offenders may require help meeting basic life needs, such as finding housing, applying for a job, or cooking a meal. Moreover, counselors generally will have to motivate clients to find new ways to manage their feelings, control impulses, and work toward concrete goals. Confronting manipulation and setting boundaries are constant challenges for many substance abuse counselors who work with criminal justice clients.
This section discusses some of the issues that the counselor is likely to face, along with strategies for meeting those challenges. The second part of this chapter, “Program Components and Strategies” addresses a broader range of strategies.
It is difficult to label any particular needs of offenders who abuse substances as more basic than others. Offender needs vary depending on issues such as their legal status, gender, culture, sexual orientation, age, and functional capacities. There are also significant differences in what an individual experiences in different criminal justice settings (i.e., jail, prison, community supervision). Despite these differences, there are commonalities in the treatment needs of offenders. In addition to substance abuse treatment, offenders typically require the following services:
Detoxification
Screening and assessment (see Chapter 2)
Treatment for co-occurring mental disorders (see chapters 2, 3, 4, and 6)
Treatment for physical health issues
Family-related services such as visitation, childcare, and reunification
Case management
Legal assistance
Vocational skills development and employment
What varies from offender to offender is the emphasis placed on particular needs and the treatment and related services available to meet those needs. The following highlights some of the more salient issues offenders face—detoxification, homelessness, and life skills. For more information on assessing and meeting basic needs, see chapters 2, 3, and 4.
Chapter 2 provides information on how to identify offenders in need of detoxification services. However, even if a counselor does not perform screening and evaluation, he or she should be aware of the signs and symptoms of withdrawal. Sometimes offenders in need of detoxification are not identified at intake because they lied about the extent of their substance use, there was no reason to suspect substance dependency, or withdrawal symptoms were mistaken for mental illness. Offenders who experience withdrawal without medical attention are at risk for serious health consequences, and withdrawal from some drugs (e.g., alcohol, barbiturates) even carries a risk of death.
Symptoms of withdrawal vary according to the substance abused, but signs that may be noted by the counselor include
Anxiety, restlessness, irritability, panic attacks, insomnia
Profuse sweating, muscle jerks, constant blinking
Yawning, sleepiness, exhaustion, lethargy
Depression, crying fits, disorientation
Suicidal thoughts or behavior
For some drugs, symptoms of withdrawal can be prolonged. For example, the insomnia and anxiety common in people with benzodiazepine dependency can continue for months following discontinuation of use (Federal Bureau of Prisons 2000). For offenders undergoing treatment for withdrawal, the counselor should work closely with the medical team to ensure that symptoms are identified and treated.
For more on information on detoxification, see Chapter 2 of this TIP and the forthcoming TIP Detoxification and Substance Abuse Treatment (Center for Substance Abuse Treatment [CSAT] in development a).
The impact of homelessness on offenders varies depending on the particular setting in which they are being treated. Jails frequently work with homeless offenders; in fact, some people enter jail to get food and housing (and may enter substance abuse treatment programs for the same reasons). Homelessness can be a traumatic experience, and for some clients who have had to live on the streets, jail may be the safest environment in which they have lived for some time. Those used to being homeless may need to relearn how to live their lives in a stable environment.
Some offenders may have become homeless because of their incarceration in jail or prison. Even if homelessness was not an issue when the offender was arrested, it is likely that an offender will be homeless upon release. In some instances, people who have served their full sentence (and therefore are not being released on parole) enter the community without aftercare options or any plan for housing.
Counselors should be aware that a great deal of stigma and shame is attached to homelessness, and many clients are reluctant to discuss it without prompting. Panel members have had experiences with clients who were willing to talk about criminal activity, substance use, and past trauma before they were willing to discuss the fact that they were homeless. One way to obtain this information is to ask offenders where they lived in the month prior to incarceration or arrest and if they anticipate being homeless upon their release. A plan should be in place to provide offenders with housing if they are leaving a prison facility. In all cases, effective counselors have working relationships with personnel in housing services to which to refer offenders in need of housing.
Many offenders have hidden deficits in basic life skills (e.g., knowing how to balance a checkbook, prepare a meal, accept feedback from an employer). While these deficits are as individual as the offender, the consensus panel feels that treatment programs with criminal justice clients should address a range of instrumental skills (e.g., meal preparation, money management, laundry, resume writing), as well as some basic social skills, particularly those needed in employment and other interpersonal situations. Counselors should observe offenders to identify problem areas.
Advice to the Counselor: Homelessness.
Among the skills most underdeveloped in offender-clients are basic problemsolving skills. Because of their impulsiveness and difficulty delaying gratification, many offenders are particularly poor at breaking down moderately complex problems into the few basic steps required to get from problem to solution. Practice is needed to learn clear problem identification, generation of options, thinking through likely outcomes, option selection, trying out options, and reviewing outcomes.
Antonowicz and Ross (1994) address the need to prioritize treatment according to the criminogenic needs of criminal justice clients, particularly the specific issues that brought the client to the criminal justice system in the first place. These are most often substance abuse and criminal thinking and values. This section describes the components of criminality (i.e., criminal thinking, the criminal code, and manipulation), and suggests programmatic and clinical strategies for addressing criminality in substance abuse treatment for offenders.
A range of factors are associated with substance use among offenders, including peer substance abuse, impulse control difficulties, trouble managing negative emotions, poor problemsolving and self-management skills, impaired moral reasoning, and cognitive distortions (Wanberg and Milkman 1998). As noted, criminal thinking is especially important to address, as individuals with ingrained criminal lifestyles employ a number of cognitive distortions or “thinking errors” (see Figure 5-1).
Common Thinking Errors.
Offenders can learn to recognize thinking errors and to understand how those errors can lead to behavior that gets them into trouble (Wanberg and Milkman 1998). Strategies include
Involvement in specialized therapeutic community (TC) programs
Cognitive–behavioral group interventions focused on correcting and eliminating criminal thinking errors
Self-monitoring exercises through keeping a journal and “thought logs”
Staff and peer confrontation regarding criminal thinking patterns and related behaviors observed within treatment programs (Field 1986; Wanberg and Milkman 1998)
Advice to the Counselor: Criminal Thinking.
A number of approaches, drawing largely on cognitive–behavioral methods, have also been developed in recent years to address criminal thinking, the most popular among these being Thinking for a Change, issued by the National Institute of Corrections (NIC) (Bush et al. 2000), Gordon Graham and Company's Framework for Recovery (Graham 1999), and Wanberg and Milkman's Criminal Conduct and Substance Abuse Treatment (Wanberg and Milkman 1998). The core components of Thinking for a Change are described below. For more information on Framework for Recovery, go to http://www.ggco.com. Wanberg and Milkman's module is available as a provider's guide and participant's workbook.
Criminal thinking also can be addressed using the same paradigms used in substance abuse relapse prevention. Many of the early warning signs and risk factors for relapse will be the same or very similar to those warning signs and risk factors for the client's criminal thinking. It is important that the focus on addressing criminal thinking not become another way of stigmatizing criminal justice clients. Criminal thinking should be viewed as the outcome of maladaptive coping strategies rather than as a permanent fixture of the offender's personality.
Criminal justice client manipulativeness can be addressed by identifying “criminal thinking errors” or one of the other, similar methods of identifying cognitive distortions (Wanberg and Milkman 1998). For example, a particular client may try to avoid the work of personal change by repetitively demeaning others, including the counselor. Another client may repetitively project an attitude of giving up at every small setback (“zero state”). These maladaptive and manipulative coping strategies readily undermine the treatment process unless they are addressed.
Addressing client manipulativeness involves
Counselor or treatment group identifying the primary thinking errors they observe
Instructing the client to begin self-monitoring when these occur (journaling)
Providing regular feedback to the client, usually from peers in a treatment group
Offenders tend to have a shared value system that includes refusal both to cooperate with authority and to confront negative behavior by others. This “criminal code” or “convict code” is another part of criminal thinking that must be addressed in treatment. The criminal code explains why good treatment programs stressing personal accountability, peer support for change, and peer confrontation of negative behavior are so threatening to the offender culture. It also explains why it is often necessary to separate inmates in treatment in correctional institutions from the general inmate population.
Treatment staff need to pay attention to the extent to which their clients are being stigmatized by other offenders as “snitches” or “weak” because they participate in treatment. It is sometimes necessary to remove clients from a negative situation to give treatment a chance. Sometimes, a newer treatment group might be pressured to revert to the criminal code with antisocial values predominating over prosocial values. These situations require careful confrontation, limit-setting, and clear expectations with consequences by treatment staff.
Thinking for a Change.
Dealing with anger and hostility with criminal justice clients is much like dealing with anger and hostility with other clients. However, due to their higher incidence of antisocial personality disorder, criminal justice clients are more likely to use anger as a manipulative coping strategy and less likely to be able to separate anger from other feelings.
Clients may be angry for a variety of reasons, including
Genuine feelings of being treated unfairly
Limited affect recognition; confusing anger with other feelings
Using anger to maintain adrenaline
Goal-directed manipulative coping strategies such as deflecting attention from other issues or to keep others off-balance
Often, problems with expressed anger relate to an inability to express other feelings—a problem with affect. Interventions involve teaching criminal justice clients to recognize their affective states and to understand the difference between feelings and action. Many criminal justice clients (especially men) have limited understanding of and insight into what they are feeling at particular points in time. The counselor's goal, then, is to broaden affect (emotions) identification. For a surprising number of offenders, feeling states initially consist of “angry” and “other.” Often, what they first think is anger turns out to be frustration, hurt, loneliness, fear, etc.
Offenders who abuse substances also have a tendency to think that if they feel it, they must act on it. Learning the relationships between behavior, thinking, and feeling, and how each affects the other, is helpful to many criminal justice clients. Learning that feelings do not equal thinking or behavior can be a revelation for many offenders. Counselors should point out that feeling it doesn't make it so, nor does it mean the client has to act on the feeling. As the Alcoholics Anonymous saying states, “Your feelings are not facts.”
In summary, interventions addressing emotions should encompass
Identifying the feeling(s). Maybe other feelings are involved, such as embarrassment or guilt.
Understanding clearly where the feeling is coming from. What is the real source of the anger?
Identifying the goals the anger is serving (e.g., deflecting attention).
Identifying the goals the anger is undermining (e.g., staying out of jail or keeping a job).
Working toward taking the longer view (e.g., beginning to use a prosocial thought process to manage the anger).
Several additional strategies can help clients to recognize their feelings. For example, counselors can set boundaries on how anger and hostility can be expressed and set limits as to reasonable duration of expression of anger and hostility. Once the offender calms down, the counselor can refocus on what the client can learn from the situation and how the client can benefit in the future. Counselors can also use peers in a group setting to explore how the client might use anger and hostility for secondary gain. TC groups have “cardinal rules” that include no violence or threat of violence (justification for program removal if violated) that provide a safe environment for exploring anger issues. For more information on anger management, see Reilly and Shopshire (2002).
As offenders move through the criminal justice system, important elements in their identy can change. In the pretrial stage, their identity as a member of a racial or cultural group, a family member, or employee may be most prominent. In jails there is generally a more immediate crisis, as one grapples with the shame and stigma of being labeled a criminal and the fear of facing extensive incarceration.
In prison, some people learn a new identity based on the prison culture in which they are involved; some prisoners learn to think of themselves as criminals. In part, this is a result of institutional pressures on them, and partly it is the result of interactions with other inmates who have accepted the persona of criminal. For offenders who enter community supervision programs on release from prison, embedded criminal identities can pose a number of problems.
Regardless of whether the offender is in jail, prison, or under community supervision, the identity of an offender often is an issue that needs to be confronted in treatment. Those who have adopted a criminal identity need to learn new ways of thinking about themselves; those whose identity is shaken by the incarceration will need help coping with their criminal charges. An overall rehabilitation goal is to help offenders develop more prosocial identities consistent with positive social values.
Race and cultural background can play an important role in the life of offenders, but the dynamics of race and culture are especially pronounced in jails and prisons. In these settings, Caucasians often are in the minority for the first time in their lives. A number of subcultures are found within jails and prisons. Inmates who belong to minority groups may see correctional staff members (including treatment staff) as adversaries. Gangs represent the most significant of these subcultures, at least among male populations. Gang affiliation can influence with whom an offender is able to socialize. Thus, treatment must take into account this aspect of the offender's identity.
Family relationships are often an important part of an offender's life. Family can represent a connection to the outside world and can be a source of stability for offenders as they move through the criminal justice system. Moreover, the quality of the offender's relationship with his or her family can be an important factor in recovery. Slaght (1999) reported that the only independent variable related significantly to relapse at 3 months after release to the community was whether the offender was getting along with family members. Those who were getting along very well with family members were the least likely to use drugs. Based on this, Slaght recommends more extensive efforts to involve family members in drug treatment.
Just as positive family relationships can foster abstinence, family connections also can be a source of confusion and worry for clients who see their role as a family member in conflict with their role as an inmate and/or criminal. This can be especially true for parents. According to the Bureau of Justice Statistics, in 1999 the majority of State and Federal prisoners reported having at least one child under the age of 18 (Mumola 2000). For many of these offenders, drug or alcohol abuse was a factor in their incarceration. For example, one in three mothers in State prison committed her crime to get money for drugs, and 65 percent reported drug use in the month prior to the offense. For both mothers and fathers, 25 percent met the diagnostic criteria for alcohol abuse (Mumola 2000). In a survey of female inmates, Acoa and Austin (1996) found that nearly 20 percent of mothers were concerned that one or more children may have been exposed to substances in utero.
Advice to the Counselor: Family Involvement.
Confronting the guilt associated with their drug abuse can be important in treating parents involved in the criminal justice system. These individuals often identify themselves as “bad” parents and experience a great deal of shame over how their involvement in the criminal justice system has impacted their children. While this may be especially true for mothers, fathers also have strong feelings about their role as parents and express concern about their children. Jeffries and colleagues (2001) reviewed several parenting programs for male offenders. Descriptions of these programs are available online at http://www.vera.org/centers/family-justice-program.
Treatment that includes other family members can be of use. In some families, more than one family member is incarcerated; treating the family can address a generational cycle of incarceration. Family treatment also can prepare inmates and their families for release. Since family problems can be a relapse trigger, Slaght (1999) recommends that offenders learn how to identify and cope with family conflicts. Substance abuse treat-ment programs also can use family involve-ment as a source of motivation. For example, extended parent–child visits can be used as a reward for good behavior.
It is important to note that family involvement in recovery is not always positive. Inmates, especially those with moderate to longer sentences, often can develop a false sense of “healing” of family problems. This results from with family members and the tendency of families to shelter the inmate from problems on the outside. This false sense that family relations have changed becomes a potential stressor on release, when the inmate discovers that the previously existing problems are still present and often worsened. It is also important to note that sometimes offenders use their families to provide them with drugs and to enable their substance abuse. Family members may also be involved in criminal activity and be expected to carry on criminal activities such as drug dealing while one member is incarcerated.
Prisons and jails are hierarchical societies, and men and women can attain status within a prison or jail community often using a different set of skills and behaviors than they would use in the community. This is especially true in prisons where longer stays make status and belonging more important issues. Therefore it is possible that an offender may face a loss of status either by going to prison (and losing a job and a place in the community) or by being released from prison (where the individual may have been a leader). Providers also should be aware that the offender may have had high status and a large income on the “outside” because of criminal activity (e.g., drug dealing) and may need to deal with a loss of status when incarcerated or resist the temptation of returning to a high-paying but illegal occupation on release. In other instances, an inmate may carry status (e.g., as a gang member) into jail or prison, and may resist treatment in order to maintain that status. Regardless of the setting, the consensus panel believes that treatment activities should include opportunities for participants to “earn” status in the program.
Criminal justice clients exhibit denial in ways similar to those of other populations. For some offenders, denial is a product of their criminal thinking. The criminal justice system may help reduce denial—it is harder for an offender to deny that drugs are a problem while sitting in a cell. Treatment staff can remind clients of the reality of their legal problems as a way to break through denial.
While substance abuse treatment providers often are trained to view denial as a negative symptom of the offender's addiction, denial may be a necessary strategy to further the offender's legal goals. In some situations, offenders have incentives to admit to a substance use disorder even if they do not have such a disorder, so that they can avoid prison and enter a treatment program instead. Admitting to substance abuse can have legal consequences for the offender that need to be understood by treatment providers before they ask an offender to self-identify as an “addict” or “alcoholic.” It should also be noted that there are offenders who use or sell substances but do not have a substance use disorder.
Denial of criminal activity is a different, but related, issue. People may deny criminal activity even if they have dealt with their substance abuse. Just because an offender is in recovery from substance abuse does not mean he or she has ceased criminal activity. Treatment providers also will find that some offenders do not believe that what they have done is criminal or, at least, do not believe it is immoral. Some (e.g., gang members) perceive their actions as a normal part of daily life in their community and believe that the only problem was that they got caught. They see themselves as victimized by the law, rather than as victimizers. Others admit their substance abuse and even realize that they must cease criminal activity but deny that they have to change their lifestyle (e.g., their associations, the place they live), which can contribute to relapse.
Sending criminal justice clients to treatment under threat of direct consequences with little incentive and loss of freedoms is not effective coercion. However, coercion can be very effective at getting criminal justice clients to treatment and keeping them there (Leukefeld and Tims 1988). This is best done using incentives as well as sanctions and involving some degree of choice by the client, even if leverage is present to encourage the client to make the desired choice.
When dealing one-on-one with the criminal justice client on this issue, the consensus panel suggests the following strategies:
Avoid personalizing the situation and focus on the client's role in forcing the consequence. For example, avoid phrasing that sends the message “I'm doing this to you.” Say things such as “You sort of forced the judge into giving you this consequence for using again.”
Focus the client on the future and what she can learn from the current situation.
Be aware of cultural differences. Clients have culturally based attitudes toward authority that can affect how they respond to coercion in treatment. For example, confrontational treatment modalities may not be helpful for American Indians (Vacc et al. 1995).
Approach clients with sensitivity, understanding, and honesty. This includes paying careful attention to body language, eye contact, and tone of voice.
For more information on treating coerced clients, see TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b); the TIP includes a section titled “Motivational Enhancement and Coerced Clients” that will be of particular use in the treatment of offenders.
Advice to the Counselor: Addressing the Coerced Client.
Guilt and shame may also be a major consideration for some criminal justice clients. Offenders new to the criminal justice system, particularly first-time offenders who have recently lost much of their social standing, may struggle with guilt and shame. In some cases these feelings are realistic and may facilitate treatment, but in other cases they may be exaggerated and interfere with substance abuse treatment until they are adequately processed. As noted above, many offenders experience a significant amount of shame over their actions even if they are not willing to show it. Those who do not may either have an antisocial personality disorder (see p. 112 for more information) or come from criminally involved family or social networks where criminal behavior is expected and approved; those clients may still feel shame, but it could be because they “messed up” and got caught.
Shame can be healthy, if it can motivate people to change their lives. Making amends can be a positive way to address guilt and shame and further treatment goals. Talking about feelings of guilt and self-loathing can also help an offender reduce feelings of hostility and anger. Shame and guilt, however, can also fuel denial and can make some individuals more prone to violence in order to cover up their feelings of shame. In general, female offenders face more shame than men or are, at least, more conscious of the shame they feel.
The stigma associated with criminal behavior and substance abuse also can be very powerful but is less useful as motivation for clients. The criminal justice system does much to stigmatize the offenders in the system, and the people involved in that system (whether they be corrections officers or inmates) often reinforce guilt, shame, and stigma.
Sealed Records.
Stigma also comes from outside the criminal justice system (e.g., family, mass media, society). While it is important for offenders not to forget their past, it is not necessarily helpful that society does not allow people to move on or accept that they have paid their debts. It is also important for offenders to have appropriate role models who have overcome the stigma of a criminal past and a history of substance abuse in order to achieve something in their recovery.
While there has been some reduction of stigma attached to substance abuse and mental illness in recent years, the stigma associated with arrest, conviction, and incarceration remains very strong. Societal change occurs slowly, but treatment providers can help the situation by not burdening clients with additional stigma because they are involved in the criminal justice system. The consensus panel suggests that if crime is part of addictive behavior, then criminal behavior can be seen as another manifestation of a substance use disorder. Treatment providers need not condone an offender's past criminal activity, but they should be able to accept it as part of the client's past and not a permanent character flaw or insurmountable obstacle to recovery.
Counselors' methods for establishing a relationship with clients vary according to the setting. It is much more difficult to develop a relationship in prisons or jails than in the community because boundaries and rules limit how psychologically close one can get to incarcerated offenders. For example, while eliciting emotional responses is quite useful in psychotherapy, corrections staff generally see this as a problem to be avoided. In these settings there needs to be careful supervision to evaluate how closely counselors and clients are interacting.
Advice to the Counselor: Establishing Boundaries.
Because boundaries between staff and clients have a special significance in criminal justice settings, treatment staff need to be especially vigilant about self-disclosure. The counselor needs to ask him- or herself whether a personal disclosure is going to make a difference for the client and not just for the counselor. For example, using one's personal experience as guiding life lessons can add credibility and be helpful on a more personal level, but recent experiences that may expose too much vulnerability should be avoided. Also, recovering staff in TCs who often share personal experiences have found the practice to be beneficial when balanced with appropriate boundaries. Counselors also should not associate with clients to the detriment of their relationship with corrections and treatment staff; no matter how much empathy they feel toward offenders, counselors need to remember that they represent the criminal justice system. Offenders are often deft at conning a counselor into doing small and seemingly meaningless things for them, but this is often the first step in an unhealthy alliance that can be used against the counselor at a later date. Alternatively, a well-trained counselor can often confront the offender and turn the attempted manipulation into a step in developing a stronger treatment alliance.
While it is not always easy, given the boundary issues that exist in criminal justice settings, the creation of a therapeutic alliance is very important when working with this population. Of course, the ability to create this alliance and its relative importance varies according to staff ability, experience, and training. In jails, it may be less crucial because clients may remain in treatment only a short time. It may, however, be most critical in community supervision settings if clients are engaged in outpatient treatment. In residential programs, such as therapeutic communities, peers play a larger part in the treatment experience, and the client's relationship with his or her peers is often as important as or more important than the relationship with the counselor.
Relationships with criminal justice staff are often quite important in the therapeutic process. This is especially important for offenders under community supervision, as their alliance with their probation or parole officer is critical. In a prison or jail setting, it also helps to include corrections staff as part of the treatment team, but clients should be told if this is going to be the case. When probation officers or corrections staff members are part of the treatment team, roles need to be very clearly defined. Because they may lack experience in treatment, corrections officers can become too involved in the treatment process and become overly distraught over treatment failures. In order to operate within a prison or jail, corrections staff need to maintain a certain degree of distance from offenders as well as keep their respect. The consensus panel recommends that treatment programs that are going to involve corrections staff or probation officers should provide extensive cross-training between corrections and substance abuse treatment staffs. The legal issues surrounding confidentiality, for example, are a suitable subject for cross-training.
Counselors working in any treatment setting need to maintain credibility with their clients.
If offenders believe that treatment staff are competent, they will be more influenced by the treatment and less likely to return to incarceration. Research by Broome and colleagues (1996a) showed that high self-esteem and high ratings of counselor competence were associated with a significant reduction in recidivism by probationers ending their treatment. Strauss and Falkin (2000) found similar results with a cohort of female offenders. Their data indicate that clients who successfully completed treatment had more favorable perceptions of staff within the first 2 weeks of treatment than those who did not.
Cultural competence is an important factor in developing a counselor–client relationship. Programs should have a culturally diverse staff that reflects the diversity of the population they serve; however, that is not always possible. What is possible is that staff be trained to understand cultural issues affecting the populations in the area in which they work. Cultural issues reflect a range of influences and are not just a matter of ethnic or racial identity (e.g., Ohio prisons have a large number of inmates from Appalachia, and staff there need to understand that culture). Special training programs can be developed to help counselors attain cultural competence for the cultures the agency serves. (The forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment [CSAT in development b] provides indepth information on developing cultural competence and providing culturally competent treatment.)
Advice to the Counselor: Establishing Counselor Credibility.
The concepts behind the stages of change model of recovery (Prochaska et al. 1992) were introduced and summarized in Chapter 3. While these are important concepts in recovery generally, they are particularly relevant in the treatment of criminal justice clients because so many of these clients are in the early stages of change. Figure 5-2 (next page) summarizes treatment strategies based on the offender's stage in recovery.
Strategies for Working With Offenders Based on Their Stage in Recovery.
Counselors with criminal justice clients often find they spend much of their time working in the precontemplation and contemplation stages. This can be discouraging to some, but the trade-off is that this is important work that reduces both crime and the number of crime victims, in addition to rehabilitating offenders.
The initial goals of substance abuse treatment are to “get them there” (engagement) and to “keep them there” (retention). This section addresses programmatic strategies to foster both engagement and retention and discusses other program components that promote effective substance abuse treatment for criminal justice clients.
Arrest and incarceration can provide an important opportunity to identify substance abuse and other psychosocial problems, to provide stabilization of acute needs (e.g., detoxification from alcohol or opioids, medication for psychotic or depressive symptoms), and to engage offenders in substance abuse treatment services (Peters and Kearns 1992). Jails, prisons, and community diversion or supervision programs often serve as the first point of contact for offenders who have substance abuse problems. Motivation to enter treatment frequently occurs at particularly stressful times such as after being arrested, after one's children have been removed by authorities, or following an overdose or a “bad high.” Substance abuse treatment staff need to watch for these opportune times and respond quickly so that the client can be engaged in treatment while the motivation is still strong. Most of these individuals have not had previous contact with substance abuse treatment agencies, and their first involvement in treatment services is frequently while in jail or prison (Mumola 1999).
In the community, the usual sanction for refusing to participate in treatment is loss of freedom—often incarceration. In jails and prisons it usually involves longer incarceration times. At the point of decision of whether or not to participate in treatment, the offender usually faces more sanctions than incentives to participate, and the sanctions may be severe.
A key point in “getting them there” is to be sure that disincentives to program participation are minimized. For example, if offenders lose freedoms or have worse housing (in institutions) as a result of program participation, many will not give treatment a chance.
While legal pressures may be sufficient to get a client into treatment, engagement is necessary if the client is to become motivated to commit to change and maintain recovery (Hubbard et al. 1988). Therefore, treatment programs need to be aware of the common characteristics of clients who leave treatment early and use this knowledge to develop approaches that motivate these clients to stay in treatment.
In a study of offenders on probation, Broome and colleagues (1996a) looked at three client background factors that are associated with treatment outcomes to see if they had an effect on establishing therapeutic relationships. Recognition of the existence of a substance abuse problem was associated with a positive therapeutic relationship and engagement in treatment, while the degree of peer deviance in the client's social network and family dysfunction was not. The fact that recognition of substance abuse problems was a positive indicator for successful engagement in treatment lends support to the use of motivational approaches that help the client recognize he or she has a problem with substance abuse.
“Coercion” means using incentives and sanctions to encourage program participation. In some jurisdictions, coercion may come in the form of legal mandate to treatment. This rarely affects offenders already sentenced to prison, but it often affects clients under community supervision who may need to be involved in treatment as part of their probation or parole. Clients under community supervision also may elect to enter treatment to avoid harsher alternatives (such as involuntary admission into a mental hospital) or negative repercussions (such as losing custody of one's children). Individuals convicted of driving while under the influence may be required to complete a psychoeducational class to retain their driver's license. The California initiative known as Proposition 36 offers a choice between incarceration and probation with substance abuse treatment to first- or second-time offenders convicted of nonviolent drug possession charges (see Chapter 11 for more information). Arizona has enacted a similar law, and other States have them under consideration. Offenders may also receive pressure from other governmental agencies (e.g., child protective services agencies) to enter or continue treatment, as part of community supervision or while in jail or prison. Not all forms of coercion are explicit for clients involved in the criminal justice system; people may receive reduced sentences or avoid incarceration in a higher security facility if they enter treatment.
Roberts and Nishimoto (1996) studied retention in treatment among a group of women who were cocaine dependent, many of whom were under criminal justice supervision. The type of treatment services provided to the women made the largest difference in retention. The authors concluded that the intensity of the treatment, its structure, and the existence of woman-focused programming engaged the clients. However, greater levels of severity of a substance abuse problem also predicted shorter stays in treatment, and previous substance abuse treatment increased slightly the risk of dropping out.
Does Coerced Treatment Work?
Other research has shown that early dropout from treatment in criminal justice settings is correlated with having a history of psychiatric treatment, high levels of anxiety and depression, unemployment immediately prior to sentencing, cocaine dependence, lower levels of self-efficacy, and social networks that demonstrate low levels of social conformity (Hiller et al. 1999b). These authors found that the strongest predictor of treatment dropout was a high score on a criminality classification system they developed based on the Lifestyle Criminality Screening Form (Walters et al. 1991) that measured aspects of an offender's lifestyle related to criminality (e.g., irresponsibility, self-indulgence, interpersonal intrusiveness, social rule-breaking). Lang and Belenko (2000) found that offenders in a diversionary treatment program for felony drug offenders who completed treatment had higher levels of social conformity and more friends, fewer drug felony convictions, less involvement in psychiatric treatment, less income from drug dealing, less unprotected sex, and fewer injuries from gunshots or stabbings.
While many of the factors that correlate with treatment dropout cannot be altered, the consensus panel suggests that some changes to treatment programs can be developed based on these studies. For one, there seems to be general agreement that a client's friends can have a good deal of influence on whether that person will successfully complete treatment. Developing positive peer networks should therefore be a priority for retaining offenders in treatment.
A history of co-occurring mental illness, as demonstrated through a history of mental health system involvement, can have a significant negative effect on treatment retention. High rates of co-occurring mental illness have been documented in the offender population (estimated to be 7.4 percent in Federal prisons, 16.2 percent in State prisons, and 16.3 percent in jails) (Ditton 1999), suggesting a need for treatment programs tailored for offenders with co-occurring disorders in order to reduce dropout rates.
The consensus panel also recommends that coerced individuals be mainstreamed with noncoerced clients where possible—such as in community settings—and should not be separated into different treatment tracks. Coerced treatment is much less likely to work if only similarly coerced individuals participate in the program. Because research showed that coerced treatment can be effective under some circumstances, some criminal justice systems developed new programs for these clients that did not build on existing programs; clients in these programs do not seem to have fared as well because they lacked community support from clients who were committed to treatment. It is not always clear that treatment models are followed accurately (Farabee et al. 1999). Administrators should avoid creating coercive programs with minimal resources.
There is a risk that treatment could become overly coercive and susceptible to charges of cruel and unusual punishment. It is important that participants in treatment be offered the opportunity to leave the program after a minimum time period (e.g., 90 days). The use of experienced outside contractors and recovering staff can help reduce the mistrust.
Once the offender enters treatment, more options usually become available for creative use of incentives and sanctions to keep the offender in treatment. It is important to continue to push for a preponderance of incentives over sanctions to motivate offenders (Gendreau 1995). Because of the manipulative coping strategies and evidence of criminal thinking that bombard treatment staff daily, it is all too easy to focus on the negative behaviors instead of “catching people in the act of doing good work.” But positive reinforcement is relatively more powerful than sanctioning in changing behavior as well as other aspects of personal growth.
The types of incentives to use are limited only by creativity. Beyond reduced supervision, other incentives can be greater access to other services (e.g., employment training or improved housing), higher status within the treatment group or community, or even variations on a token economy can be considered. The point is to continue to refocus on reinforcing desired behavior, look for additional ways to motivate the clients from a positive perspective, and to remember that most people begin and sustain personal change out of external motivation (the internalized motivation comes later).
The key points in effective use of incentives and sanctions are:
Emphasize incentives over sanctions. Gendreau (1995) has suggested that 4:1 is optimal.
Sanctions should be applied as rapidly as possible. The longer the time period between the undesired behavior and the consequences, the less effective the consequences.
Repetitive use of mild sanctions (implemented quickly) is more effective than repetitive threats of sanctions followed by an intensive sanction (e.g., incarceration).
Be creative with incentives.
Treatment staff and criminal justice staff should collaboratively apply incentives and sanctions.
Prosocial activity is any positive activity. In other words, criminal justice clients will do better in treatment when kept busy doing any positive activity. Most criminal justice clients tolerate boredom poorly. This is probably partly due to the high incidence of antisocial personality disorders and attention deficit disorders within this population (Jemelka et al. 1994; Wender et al. 2001). Offenders tend to demonstrate high excitement needs coupled with poor delay of gratification (Field 1986). Without positive activity, criminal justice clients tend to use unstructured time for antisocial thinking and behavior. Therefore, regardless of content, the consensus panel believes that treatment programs need to be heavily structured, particularly for clients who are early in the change process.
Criminal justice clients are particularly sensitive to what staff actually do, in contrast to what staff say. Words about personal accountability with this population will have only modest impact unless staff are willing to model the behavior and hold themselves to the same standards. The modeling of this behavior, of insisting on demonstrating one's accountability instead of waiting for others to demand it, can be very powerful in helping criminal justice clients change. This is another point of collaboration between treatment staff and criminal justice staff, as both need to model personal accountability in their behavior.
Peers usually have more opportunity than staff to observe each other's behavior. Peers using a group treatment modality have the capacity to give more immediate feedback for positive steps to change and for negative thinking and behavior. Peers can often give feedback in ways that the client can more readily assimilate. Criminal justice clients often quickly and accurately see the relapse signs in others well ahead of the time they are able to see relapse signs in themselves. Using peer support and feedback also serves to prepare incarcerated criminal justice clients for using peer support organizations in the community.
Many criminal justice clients have little experience with success with prosocial endeavors. Dividing programs into identifiable phases can provide markers of accomplishment and progress and focuses treatment efforts at steps along the way. Typically, residential programs include orientation, treatment, and reentry phases.
Once personal change occurs during treatment, a sustained effort is required to maintain that change, namely relapse prevention and recovery planning. Relapse prevention is “a systematic method of teaching recovering patients to recognize and manage relapse warning signs” (Gorski and Kelley 1996, p. 15). For more on relapse prevention for criminal justice clients, see the Technical Assistance Publication Series Number 19: Counselor's Manual for Relapse Prevention with Chemically Dependent Criminal Offenders (Gorski and Kelley 1996).
There are several advantages to using relapse prevention as a general approach throughout criminal justice programs:
Relapse prevention is a key issue for community supervision. Beyond the obvious applicability of self-management training to offenders, this work provides key information to parole and probation officers. If the supervision officer knows that a primary overt relapse sign for a particular offender is isolating in his room, for example, the officer has critical supervision information. Knowing an offender's early warning signs for relapse is probably as important to supervision as employment and living situation.
Relapse prevention emphasizes taking responsibility for oneself. Relapse prevention work makes it difficult for the offender to blame others. Self-management training puts responsibility squarely on the individual. The occurrence of a partial or full relapse is a signal that the individual has more work to do in developing or performing his own relapse prevention and recovery plan. Relapse prevention work, then, can be a primary means of moving from necessary external controls (on the offender) early in treatment to the needed internal controls (from the offender) later in treatment.
Relapse prevention work emphasizes the long-term nature of many disorders. Many major life problems, such as addictions, are life-long problems, requiring continuing work by the individual. The concept of relapse prevention implicitly communicates this point to criminal justice clients.
Relapse prevention work is easy to communicate. Warning signs in the individual's behavior, and specific actions by the individual in response to those signs are easy to communicate between corrections program staff, offenders, supervision officers, and others in the offender's support network. Relapse prevention plans aid communication from institutional programs to community supervision and to community programs.
Relapse prevention is applicable across theoretical perspectives. Practitioners from the theoretical perspectives of behaviorism and disease concepts are currently using relapse prevention and recovery planning techniques with equal facility. Relapse prevention strategies seem to ring true regardless of beliefs about the etiology of addictions or criminality.
Relapse prevention is a unifying concept across programs. Whether the problem is alcohol abuse, drug abuse, mental illness, sex offending, or criminality generally, the same basic process seems to occur in relapses, and the same basic strategies seem to be needed in recovery. Relapse prevention work therefore offers a unifying concept and means of communication across types of programs and service populations.
Spiritual approaches have been used in combination with substance abuse treatment services and can provide powerful tools for some to achieve sustained abstinence. There are, however, limitations to what can be done in a public institution such as a jail or prison. While a distinction should be made between “spiritual” and “religious” practices (the former being concerned with one's own identity and a connection to a greater whole, the latter involving the formal practice of a system of beliefs), such a distinction is not always perceived by criminal justice authorities. Because of issues concerning the separation of church and State, it can be difficult for treatment programs to provide any kind of specific religious activities. However, treatment providers can refer clients to the religious leaders of their choice for additional counseling. Treatment programs can also accommodate voluntary 12-Step groups that do not explicitly endorse any one religion.
Advice to the Counselor: Spiritual Approaches.
To provide inmates in jails and prisons with opportunities for spiritual growth, programs can be creative to avoid promoting religion while still facilitating spiritual practices. Some spiritual practices, such as American Indian sweat lodges, have been instituted on the grounds that they are an important cultural activity. Some prison programs use rituals to mark certain events (which provide a way for people to express themselves without using words). Rituals and ceremonies, even if they are as simple as having a meal together, can be very important for these clients because they do not have positive rituals in their lives. The only ceremonies they may have experienced may revolve around gang activity or substance abuse. Other suggestions for promoting spiritual practices include designating an area for meditation and acknowledgements of achievements. Providing a place for such activities is an important step in promoting them. It can also be helpful to schedule times for meditation or silent reflection.
The offender-client should be encouraged to become involved in the spiritual and religious practices with which he or she is most comfortable. Jails and prisons should enable offenders to receive spiritual guidance from religious figures of all persuasions. Clients should be encouraged to connect with the religious or spiritual tradition with which they associate most closely and to think about how that tradition can help them understand their own lives and what may be missing in them. Interest in faith-based substance abuse treatment programs has opened avenues for treatment improvement that have been less accessible. Many of the “transformational” aspects in religion are similar to effective treatment components, especially relevant in self-help and therapeutic community approaches. Some examples of the common elements include the concept of transformation, credible role models, behavioral rules, the centrality of positive social values, community membership and participation, rituals and celebrations, and stages of change. In addition, consideration of a faith-based perspective offers additional support for treatment that is not usually considered, such as inviting an offender's church of choice to consult and provide resources for the postrelease planning process.
The consensus panel believes that several points and recommendations in this chapter deserve highlighting, as follows:
Whenever possible, treatment should be modified as needed to meet the individual client's specific needs. A thorough client assessment covering multiple dimensions will enable treatment providers to determine what modifications to treatment are required.
Individual needs should be considered in adapting the sequence, focus, and intensity of treatment.
It is important for offenders to have appropriate peer and staff role models who have overcome the stigma of a criminal past and a history of substance abuse. Provisions should be made whenever possible to allow criminal justice programs to hire staff who are ex-offenders and who are in recovery. Treatment programs have found it useful to maintain a blend of recovering and non-recovering staff.
While legal pressures may be sufficient to leverage a client into treatment, specific engagement strategies are necessary if the client is to be motivated to commit to change and to maintain recovery.
Anxiety, guilt, and remorse related to past substance abuse and criminal behavior can be productive in motivating offenders to change their lives. Making amends to those who have been harmed by past behaviors is one strategy that can be used to positively address these emotions.
There is a risk that treatment could become overly coercive and susceptible to charges of “cruel and unusual punishment.” It is important that participants in treatment be offered the opportunity to leave the program after a minimum period of time (e.g., 90 days).
Internal motivation for treatment is a better predictor of retention than external motivation. The panel recommends targeting those with low internal motivation for an intervention to increase readiness.
Motivation to enter treatment frequently occurs at particularly stressful times such as after being arrested, after one's children have been removed by authorities, or following an overdose or a “bad high.” Substance abuse treatment and criminal justice staff should watch for these opportune times and respond quickly so that the client can be engaged in treatment while their motivation is still strong.
While clients in criminal justice settings are often coerced and resistant to treatment, they can become invested in treatment through the use of motivational interviewing and similar techniques.
Clients who agree to enter treatment may be seen as “traitors” by other offenders, as the prison culture makes it a point to resist anything that is seen as a further attempt to control the lives of inmates. For this reason, it is useful to provide treatment services in residential areas or separate prisons that are isolated from the general inmate population.
In jurisdictions that involve probation/parole officers or corrections staff in treatment team activities, roles need to be very clearly defined. Criminal justice staff who do not have treatment-related experience or specialized training can become overly involved in the treatment process and overly invested in treatment issues.
Criminal justice professionals have been effectively involved in facilitating psychoeducational groups and other treatment activities and are often included in treatment teams and treatment and discharge planning. Criminal justice professionals providing group treatment services should receive specialized training in therapeutic techniques and treatment approaches and should consider obtaining substance abuse certification and licensure.
Many correctional treatment programs in jails and prisons have found it useful to establish co-coordinators from both treatment and correctional/security systems. These arrangements provide a sense of joint “ownership” of treatment programs, enhance program credibility among correctional officers, and provide an effective mechanism for addressing critical incidents and solving problems that affect both treatment and corrections staff.
To operate within a prison or jail and maintain inmates' respect, corrections and treatment staff need to maintain a certain distance from offenders. Cross-training can assist staff in defining appropriate “boundaries” that should be maintained in relationships with inmates, and to identify related situations that can compromise the effectiveness of security/public safety and treatment operations.
Treatment providers need not condone an offender's past criminal activity, but they should accept it as part of the client's past, and not a permanent character flaw or insurmountable obstacle to recovery.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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