**Quick Guide for Clinicians**

**Based on TIP 44**

***Substance Abuse Treatment for Adults in the Criminal Justice
System***

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

**Contents**

Why a Quick Guide?

What Is a TIP?

Introduction

Screening and Assessment

Triage and Placement

General Treatment Issues in the Criminal Justice System

Treatment Issues in Pretrial and Diversion Settings

Treatment Issues in Jails

Treatment Issues in Prisons

Treatment Issues for Offenders Under Community Supervision

Treatment Issues for Specific Populations

Glossary of Terms

**Quick Guide for Clinicians**

Based on TIP 44

*Substance Abuse Treatment for Adults in the Criminal Justice System*

This Quick Guide is based entirely on information contained in TIP 44,
published in 2004, and based on information updated through August 2005.
No additional research has been conducted to update this topic since
publication of the TIP

**WHY A QUICK GUIDE?**

This Quick Guide was developed to accompany *Substance Abuse Treatment
for Adults in the Criminal Justice System*, Number 44 in the Treatment
Improvement Protocol (TIP) Series published by the Center for Substance
Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA).

This Quick Guide is based entirely on TIP 44 and is designed to meet the
needs of the busy clinician for concise, easily accessed "how-to"
information.

The Guide is divided into 12 sections to help readers quickly locate
relevant material. For more information on the topics in this Quick
Guide, readers are referred to TIP 44.

**WHAT IS A TIP?**

The TIP series has been in production since 1991 and currently numbers
44 volumes. This series provides the substance abuse treatment and
related fields with consensus-based, field-reviewed guidelines on
substance abuse treatment topics of vital current interest.

TIP 44, *Substance Abuse Treatment for Adults in the Criminal Justice
System*

-   Updates and combines TIPs 7, 12, and 17

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-   Provides relevant information that will inform and enable treatment
    providers to improve their approach to offender and ex-offender
    populations

-   Helps professionals in community treatment to understand the
    criminal justice system and how it works in step with their
    treatment services

-   Encourages collaboration between the criminal justice and treatment
    communities.

See the end of this document for information on how to order TIPs and
other related products.

**INTRODUCTION**

Research consistently demonstrates three trends relating to substance
abuse treatment and criminal justice: (1) there is a strong connection
between criminal activity and substance abuse; (2) participation in
substance abuse treatment reduces recidivism (return to criminal
behavior); and (3) the reduced criminal activity associated with
substance abuse treatment for offenders is cost-effective.

In response to these findings, policymakers have implemented a wide
variety of strategies at the Federal, State, and local levels, aimed at
improving the availability and quality of treatment for offenders.
However, although an increasing number of criminal justice programs
offer some form of treatment, the actual number of programs and slots
remains limited, and the number of offenders in need of services
continues to rise.

TIP 44 and this Quick Guide were developed to help ensure the best
possible treatment services for clients in criminal justice settings, by
providing substance abuse treatment professionals with the tools to
effectively interact with their clients and the criminal justice system
at all levels.

**SCREENING AND ASSESSMENT**

Currently there are no comprehensive national guidelines for screening
and assessment approaches for substance use disorders in the criminal
justice system. However, information from this section can assist
counselors in developing effective screening and referral protocols that
will enable them to---

-   Screen out offenders who do not need substance abuse treatment.

-   Assess the extent of offenders' treatment needs in order to make
    appropriate referrals.

-   Ensure that offenders receive the treatment they need, rather than
    be released into the community with a high probability of return to
    incarceration.

Basic information useful for both screening and assessment can be
acquired from any number of sources, including---

-   Booking records

-   Self-report/interview information

-   Results of instruments and surveys administered

-   Past correctional records (presentence investigations)

-   Past treatment records

-   Police reports

-   Correctional staff reports (for bail hearings, early release)

-   Prior offense records (for driving under the influence \[DUI\],
    possession, trafficking)

-   Emergency medical reports

-   Drug test results (from examination of hair, sweat, urinalysis,
    Breathalyzer®).

Some areas of concern in screening and assessment in the criminal
justice system include---

-   Accuracy of information

-   Continuity and system-wide sharing of information

-   The importance of re-screening and re-assessing

-   Timing of screening and assessment

-   Drug testing

-   Detoxification needs

-   Readiness for treatment

-   History of trauma

-   Psychopathy and risk for violence and recidivism.

For more information on each of these areas, see chapter 2 of TIP 44.

**Screening and Assessment Versus**

**Eligibility and Suitability**

In correctional settings, "screening" and "assessment" are equated with
"eligibility" and "suitability," respectively:

-   *Eligibility:* Does the offender meet the system's criteria for
    receiving treatment services?

-   *Suitability:* Is the offender suitable for the type of program
    services that are available?

**When Is a Formal Diagnosis Necessary?**

When identified with a psychiatric diagnosis that will follow them
throughout the system or even their lifetime (if entered into the
criminal justice system's computer), people sometimes feel labeled and
stigmatized. This is particularly true of diagnoses related to mental
disorders. Because symptoms of mental disorders are often mimicked by
substance abuse or withdrawal, it is particularly important to defer
diagnosis until an adequate assessment period is provided under
conditions of abstinence. Moreover, diagnostic classification can
sometimes preclude offenders from receiving needed services. Likewise, a
substance abuse diagnosis can preclude access to mental health services,
resulting in no services being rendered. A substance abuse diagnosis can
also limit an offender's access to certain work assignments or
vocational training.

To avoid these problems, formal psychiatric diagnoses should be made
based on sound clinical practice. A formal diagnosis may be required
when---

-   Reimbursement for services requires it (e.g., Medicaid or Medicare
    reimbursement is not possible without a DSM-IV-TR code)

-   Pharmacological intervention is suggested (e.g., methadone,
    Antabuse)

-   Potential psychiatric concerns emerge (e.g., when the counselor is
    trying to rule out substance abuse or when symptoms may be
    substance-induced or psychiatric)

-   The counselor needs to clarify co-occurring disorders that affect
    treatment decisions

-   The information is for research or evaluation purposes.

**Screening Instruments**

In one recent study, eight different substance abuse screening
instruments were examined for use among male prisoners. Each of the
instruments was found to have adequate test--retest reliability,
although the validity of the instruments varied. The screening
instruments examined in the study included---

-   Alcohol Dependence Scale (ADS)

-   Addiction Severity Index--Alcohol Use subscale
    (ASI-Alcohol)---*Reproduced in appendix C of TIP 44*

-   ASI--Drug Use subscale (ASI-Drug)---*Reproduced in appendix C of TIP
    44*

-   Drug Abuse Screening Test (DAST-20) *Reproduced in appendix C of TIP
    44*

-   Michigan Alcoholism Screening Test (MAST short
    version)---*Reproduced in appendix C of TIP 44*

-   Substance Abuse Subtle Screening Inventory-2 (SASSI-2)

-   Simple Screening Instrument for Substance Abuse
    (SSI-SA)---*Reproduced in TIP 42, Substance Abuse Treatment for
    Persons With Co-Occurring Disorders* (CSAT 2005)

-   Texas Christian University (TCU) Drug Screen (TCUDS)---*Available at
    www.ibr.tcu.edu*.

**Assessment Instruments**

A wide variety of substance abuse assessment instruments is available
for use in the criminal justice system. The most widely used instrument
is the ASI, which is reproduced in TIP 38, *Integrating Vocational
Services With Substance Abuse Treatment* (CSAT 2000). The ASI provides a
structured interview format to examine seven areas of functioning that
are commonly affected by substance abuse, including drug/alcohol use,
family/social relationships, employment/support status, legal
involvement, physical health, and mental health.

The ASI has been normed and validated for use in criminal justice
populations. However, significant training is needed to administer and
score the instrument. The interview version of the ASI requires 45--75
minutes to administer, although the alcohol and drug use sections
require considerably less time.

For more information on screening and assessment, see chapters 3 and 4
and appendix C of TIP 44.

**TRIAGE AND PLACEMENT**

The continuum of treatment includes three major categories: pretreatment
services, outpatient treatment (including relapse prevention), and
inpatient treatment (including residential care). Several types of
program services are often available at each level; offender-clients
should be matched not only on the intensity of services they need, but
also on the particular components responsive to their individual needs.
Pretreatment services other than detoxification, including primary
prevention and early intervention, are not typically used in criminal
justice settings.

**Key Triage and Placement Activities**

The following activities can be jointly undertaken by a team of
correctional and clinical staff:

-   Developing a treatment placement database of treatment resources
    available in the community or correctional facility;

-   Defining key characteristics of existing treatment programs and the
    types of offenders and associated levels of treatment needs with
    whom the programs are most successful;

-   Documenting the referral process with appropriate timeframes and
    communication requirements for each system;

-   Outlining the information to be shared between agencies and
    developing procedures for transfer of key information without
    breaching confidentiality;

-   Describing offender treatment and supervision/management
    responsibilities for each organization to avoid duplication of
    efforts, interagency conflict, and lapses in monitoring offenders;

-   Evaluating the effectiveness of treatment matching practices and
    placement criteria on an ongoing basis; and

-   Determining offenders' eligibility for and access to health, mental
    health, and social services in the community.

**Triage and Placement Strategies**

In some criminal justice settings (e.g., jails) limited types of
services are available. In such cases, elaborate triage and referral
systems are unnecessary, and placement decisions are often based on a
brief substance abuse screening and a brief risk screening (e.g., for
violence, acute mental health symptoms) to determine eligibility.

In settings that feature a range of treatment services, the triage and
placement process may involve multiple staff and compilation of multiple
sources of information. These settings often use a scoring system or
"algorithm" to determine which offenders should receive priority for
available treatment slots.

Research indicates that treatment programs targeting offenders with
moderate to high risk for recidivism produce the greatest post-treatment
reductions in recidivism and are cost effective. However, research does
not support placement of moderate- to high-risk offenders in minimally
intensive treatment services (e.g., educational groups, 12-Step groups)
unless additional, more intensive services are also provided.

**Implementing a Treatment Planning Process**

Several factors should be considered when implementing a treatment
planning process:

-   *Offender involvement in the development of the treatment plan:* It
    is essential for offender-clients to be involved in setting case
    management goals that are in their own best interests.

-   *Coordination of treatment planning and sharing of treatment
    information:* Treatment planning activities in criminal justice
    settings should include the full range of professionals who are
    involved in supervising, monitoring, or providing therapeutic
    services. In noncustody settings, it is useful to have probation and
    parole officers involved, in addition to staff from halfway houses,
    employment/vocational services, and family members. In custody
    settings, treatment planning should involve case management or
    transition staff who may be responsible for coordinating prerelease
    plans and making arrangements for treatment appointments following
    release. Treatment plans should be updated at different transition
    points (e.g., following release from custody, transfer to less
    intensive supervision status, departure from halfway house setting).

-   *Linkages with community treatment:* An effective treatment program
    will develop and maintain linkages and agreements with agencies that
    provide educational, vocational, legal, health, and mental health
    services. For these links to work most effectively, the treatment
    plan must include all relevant information about the client that may
    be needed by the community providers.

**Compiling Information To Guide Triage and Placement Decisions**

***Risk for Criminal Recidivism***

-   Criminal history

-   Age, education, marital status, employment history

-   Characteristics of psychopathy (e.g., entitlement, impulsivity,
    superficial interpersonal relationships, lack of empathy,
    sensation-seeking, poorly controlled anger)

-   Family and social network (positive/prosocial versus
    negative/procriminal)

-   Other personality disorders

*Instruments* (use of some of these instruments is described in chapter
2 of TIP 44)

-   Psychopathy Checklist---Revised (PCL-R) and the Psychopathy
    Checklist---Screening Version (PCL-SV)

-   Psychopathic Personality Inventory (PPI)

-   Level of Services Inventory---Revised (LSI-R)

-   Millon Clinical Multiaxial Inventory---III (MCMI-III), Correctional
    Form (requires a degreed psychologist to administer)

-   Personality Assessment Instrument (PAI)

-   Novaco Anger Inventory

-   Jesness Inventory

-   Paulus Deception Scales

-   Inventory of Sensation Seeking

***Level of Substance Abuse Problems***

-   Substance dependence symptoms

-   Substance-abuse--related arrests (e.g., DUI, DWI, drug possession
    and sales)

-   History of substance abuse (frequency, quantity, type of substances,
    route of administration)

-   Drug test results or other pre- or postsentence information related
    to substance abuse

-   History of involvement in substance abuse treatment services

*Instruments* (use of these instruments is described in chapter 2 of TIP
44)

-   ASI

-   SSI-SA

-   TCUDS

-   ADS

***Level of Mental Health Problems***

-   Acute mental health symptoms that can influence the offender's
    ability to participate in individual or group treatment

-   Suicidal or other violent behaviors

-   Cognitive and interpersonal or social impairment caused by current
    mental health symptoms, specifically related to attention and
    concentration, problemsolving skills, interpersonal skills, and
    frustration tolerance

-   Effects of stress and other environmental influences on mental
    health symptoms and related behavioral problems

-   Likelihood of recurrence of mental health symptoms and behavioral
    problems given environmental conditions in available treatment
    programs

-   Accommodations available in existing treatment programs to address
    mental health symptoms and behavioral problems

*Instruments* (use of these instruments is described in chapter 2 of TIP
44)

-   Minnesota Multiphasic Personality Inventory (MMPI) (requires a
    degreed psychologist to administer)

-   MCMI-III

-   Symptom Checklist 90---Revised (SCL90-R)

-   Brief Symptom Inventory (BSI)

***Offender Characteristics***

-   Perceived severity of drug and alcohol problems

-   Interest in making a positive change

-   Steps taken by the offender to reduce alcohol or drug use

-   Perceived importance of receiving substance abuse treatment

*Instruments* (use of these instruments is described in chapter 2 of TIP
44)

-   Circumstances, Motivation, Readiness, and Suitability Scale (CMRS)

-   Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)

-   University of Rhode Island Change Assessment Scale (URICA)

**GENERAL TREATMENT ISSUES IN THE CRIMINAL JUSTICE SYSTEM**

**Addressing Criminality**

Criminal thinking should be viewed as the outcome of maladaptive coping
strategies and the environment, not as a core dynamic of the offender's
personality. In this context, treatment programs for criminal justice
clients should address the components of criminality: criminal thinking,
the criminal code (the shared values system among inmates), and
manipulation.

***Criminal Thinking***

A number of structured curricula have been developed to help offenders
recognize thinking errors and understand how they can lead to behavior
that gets them into trouble. Strategies include---

-   Involvement in specialized therapeutic community (TC) programs;

-   Cognitive--behavioral group interventions focused on correcting and
    eliminating criminal thinking errors;

-   Self-monitoring exercises (e.g., keeping a journal or "thought
    log"); and

-   Staff and peer confrontation regarding criminal thinking patterns
    and related behaviors.

***Criminal Code***

The "criminal code" or "convict code" can include a refusal to cooperate
with authority or confront negative behavior by others. Treatment staff
need to pay attention to the extent to which their clients are being
stigmatized by other offenders as "snitches" or "weak" because of their
participation in treatment. It is sometimes necessary to remove clients
from a negative situation in order to give treatment a chance (i.e.,
separate inmates in treatment from the general inmate population).

***Client Manipulativeness***

Client manipulation can be addressed by identifying "criminal thinking
errors" or one of the other, similar methods of identifying cognitive
distortions. For example, a client may try to avoid personal change by
repetitively demeaning others, including the counselor. Another client
may give up at every small setback. If not addressed, these maladaptive
and manipulative coping strategies undermine the treatment process.
Addressing client manipulation involves the counselor or treatment
group---

-   Identifying the primary thinking errors observed;

-   Instructing the client to begin self-monitoring when these occur
    (journaling); and

-   Providing regular feedback to the client, usually from peers in a
    treatment group.

**Addressing Anger and Hostility**

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, and/or goal-directed manipulative coping strategies (i.e.,
deflecting attention from other issues, keeping others off balance).

Counselors can use group settings to effectively explore these issues:

-   Identifying the feeling(s)---other feelings may be involved, such as
    embarrassment or guilt;

-   Understanding clearly where the feeling is coming from;

-   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); and

-   Working toward taking the longer view (e.g., beginning to use a
    positive/prosocial thought process to manage the anger).

**Spiritual Approaches**

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.

Some spiritual practices, such as American-Indian sweat lodges, have
been instituted on the grounds that they are an important cultural
activity. Rituals and ceremonies, even if they are as simple as having a
meal together, can be very important for clients who do not have other
positive rituals in their lives. Specific areas and times can also be
designated for meditation and acknowledgements of achievements.

Note: When referring clients to groups such as Narcotics Anonymous (NA)
or Alcoholics Anonymous (AA), counselors will want to be aware of
whether their State considers such referrals to be a violation of First
Amendment rights. Some courts have ruled that these are essentially
religious organizations.

**TREATMENT ISSUES IN PRETRIAL AND DIVERSION SETTINGS**

**Pretrial Diversion:**

**Supervision in Lieu of Detention**

An increasingly common condition of release is participation in some
form of treatment in which a pretrial supervision agency or probation
department monitors compliance. If clients fail to comply with the
conditions of release, they can be returned to jail for detention prior
to trial. Successful completion of the treatment or other conditions can
lessen a sentence if the offender is convicted. Ideally, judges should
mandate as a condition of release that offenders initiate contact with
treatment resources within 24 hours.

**Pretrial Diversion:**

**Treatment in Lieu of Prosecution**

In some instances, charges against offenders are dropped if they
complete treatment. The decision to order treatment as part of pretrial
diversion typically, though not always, rests with the prosecutor's
office. However, if the defendants fail to complete the treatment and
satisfy other conditions of diversion, they risk being sentenced more
harshly than if they had never entered the diversion program. Anxiety
about the outcome of pending charges may motivate those charged to agree
to treatment, and many treatment providers view this as an ideal
intervention point.

**Plea Bargaining**

In a plea bargain, defendants are allowed to plead guilty to lesser
charges than those they would face in a trial. A requirement that the
defendant enter treatment can be part of the plea bargain. Many systems
are finding that getting defendants into treatment at this point is
successful because the defendant is mobilized for services. In some
cases, defendants placed on waiting lists for treatment can be involved
in substance abuse education or treatment orientation groups, so that
they do not lose track of the need for recovery and treatment
involvement.

**Pretrial Diversion:\
Probation Before Judgment**

Under this framework, the defendant is placed on probation (usually
unsupervised), and the charges are pending. If the probation (which may
include court-ordered treatment) is completed successfully, then the
charges may be dropped. This happens commonly in traffic court but can
be used as an incentive within diversion programs as well.

**Presentencing**

Presentencing is the period after a guilty plea is entered (in cases
that are plea bargained) or after a conviction is handed down (in cases
that go to trial). This is another point in which linkages between the
substance abuse treatment and criminal justice systems are crucial. It
is suggested that some sort of preliminary assessment be conducted at
this stage, if one has not yet occurred in the earlier stages.

A presentence investigation is usually conducted at this time. Many
States hold serious legal constraints on sharing information contained
in this investigation. In some States no one but the judge, not even the
defendant, can see the report. However, the presentence investigation
report may contain information highly relevant to developing a substance
abuse treatment plan. To avoid duplication of efforts in gathering
needed information at various stages of the justice-treatment continuum,
planners should investigate ways to ensure that critical information
follows the individual through the process without breaching
confidentiality.

**Drug Treatment Courts**

Drug treatment courts (DTCs) provide diversion from jail or prison for
nonviolent offenders with substance abuse problems through expedited
involvement in treatment. Some drug courts have now expanded their
admission criteria to include offenders who have a history of multiple
prior offenses related to their substance abuse.

Successful implementation of DTCs has stimulated the development of
several other "specialty court" approaches for substance-involved
populations, including DUI/DWI courts, juvenile drug courts, and family
drug courts. Each of these specialty courts uses a collaborative
rehabilitation team model that involves the judiciary, treatment
providers, community supervision, and ancillary community services.

***Ten Key Components of Drug Treatment Courts***

1.  Drug courts integrate alcohol and drug treatment services with
    justice system case processing.

2.  Using a nonadversarial approach, prosecution and defense counsel
    promote public safety while protecting participants' due process
    rights.

3.  Eligible participants are identified early and promptly placed in
    the drug court program.

4.  Drug courts provide access to a continuum of alcohol, drug, and
    related treatment and rehabilitation services.

5.  Abstinence is monitored by frequent alcohol and illicit drug
    testing.

6.  A coordinated strategy governs drug court responses to participants'
    compliance.

7.  Ongoing judicial interaction with each drug court participant is
    essential.

8.  Monitoring and evaluating achievement of program goals is necessary
    to gauge effectiveness.

9.  Continuing interdisciplinary education promotes effective drug court
    planning, implementation, and operations.

10. Forging partnerships among drug courts, public agencies, and
    community-based organizations generates local support and enhances
    drug court program effectiveness.

For more information on DTCs, see TIP 23, *Treatment Drug Courts:
Integrating Substance Abuse Treatment With Legal Case Processing* (CSAT
1996).

**Treatment Accountability for Safer Communities (TASC)**

TASC programs focus on providing a bridge between treatment providers
and the criminal justice system and provide a range of services,
including screening and assessment, referral to community-based
services, monitoring of treatment progress and compliance, case
management and brokering community services, and court liaison. TASC
programs are sometimes embedded within treatment agencies or court
services departments. In other cases, they may be freestanding
organizations.

**Suggested Treatment Services for This Setting**

***Intervention Strategies***

A number of intervention strategies can be adapted within the pretrial
setting.

-   *Brief interventions*: Especially during the pretrial stage, a brief
    intervention can determine if treatment is necessary. A counselor
    can use the FRAMES approach (see p. 138 of TIP 44) or other
    motivational enhancement strategies. TIP 34, *Brief Interventions
    and Brief Therapies for Substance Abuse* (CSAT 1999), describes
    other brief interventions in more detail.

-   *Behavior contracts:* Some treatment programs use contracts with
    clients that describe precisely what is required of them. For
    example, offenders may be placed under less restrictive conditions
    of supervision if they successfully complete a pretrial treatment
    program. These behavior contracts offer rewards or incentives for
    specific behaviors. In drug court, individuals move to the next
    phase only when they complete the requirements in their contracts.
    Contingency contracts can reduce relapse and improve retention in
    treatment.

***Treatment Modalities***

In addition to previously discussed drug treatment courts and related
specialty court/diversion programs, several other types of treatment
modalities can be used effectively in pretrial settings:

-   *Sobering Stations:* Willamette Family Treatment Services in Eugene,
    Oregon, offers a Sobering Station, a 24-hour facility designed as a
    safe and clean facility where an individual can be monitored while
    coming off drugs or alcohol. Detoxification is not the specific
    purpose, though such services are offered when appropriate.

-   *Detoxification:* TIP 19, *Detoxification From Alcohol and Other
    Drugs* (CSAT 1995), describes clinical detoxification protocols for
    a variety of substances. See also the revision of TIP 19,
    *Detoxification and Substance Abuse Treatment* (CSAT in
    development).

-   *Day Reporting Centers:* Day reporting centers are used to monitor
    behavior of arrestees in the pretrial setting, and probationers and
    parolees under community supervision. They provide closer
    supervision than twice-a-week drug testing but are less restrictive
    than residential treatment.

The following components can be an important and useful adjunct to
standard counseling services offered in the pretrial setting:

-   Vocational training

-   Job readiness assessment and preparation

-   Liaison with employer

-   Literacy assessment and referral

-   Anger management training

-   Criminal thinking assessment and treatment

-   HIV education (sexual health)

-   Assistance in accessing State or Federal entitlements such as
    Medicaid; Temporary Assistance for Needy Families; Women, Infants,
    and Children Program; Food Stamps; and housing programs available
    for clients willing to enter treatment

**TREATMENT ISSUES IN JAILS**

Jails (also called detention centers) confine people during the
adjudication process. These individuals are referred to as detainees and
have not yet been sentenced. Jails also confine those sentenced to
short-term incarceration (usually 1 year or less) and serve as holding
facilities for a wide variety of reasons.

Two-thirds of the jails in the United States do not offer treatment
other than ancillary services such as assessment, self-help groups, and
educational programming. About two-thirds have self-help programs, and
about 30 percent offer detoxification.

Most individuals who do enter treatment are young, male, and, like the
general jail population, fairly evenly distributed between African
Americans (42 percent) and Caucasians (39 percent). The majority of
people (58 percent) are ordered to treatment programs as a condition of
their sentences.

A jail must operate on a schedule that includes periods of time during
which inmates are either locked in or involved in structured activities
(e.g., work), so programs compete for the inmate's time. Due to
scheduling constraints, an inmate may have to decide between enrolling
in treatment or educational programs. Ideally, treatment programming can
be developed in a modular structure that accommodates differing time
lengths and goals.

**Gang Affiliation**

The counselor should be aware of the jail's policies regarding gang
affiliation, including rules regarding who should participate in certain
programs and activities or which actions on the part of inmates may lead
to an administrative or new criminal charge. Knowledge of the gangs in
the jail may allow the counselor to foresee which activities could be
used to inflame rival gangs, to set clear group rules for activities,
and to clearly define the counselor's role of balancing security and
facility rules with good treatment practices.

**Issues Related to Legal Representation**

Attorneys do not always recognize the benefits of treatment and
therefore may not encourage the inmate's involvement in treatment.
Attorneys may also be deterred by potential legal ramifications. The
flow of information between legal and treatment professionals can also
be problematic, related to the types of information that counselors can
provide to their clients' attorneys, whether counselors can testify in
court, and the types of legal information that the treatment provider
needs for counseling purposes.

**Confidentiality**

Unique confidentiality issues can arise in small, rural jails, where
inmates and officers often know each other and keeping treatment a
private matter can be difficult. For more information about
confidentiality, see chapter 8 of TIP 44 and www.hipaa.samhsa.gov.

**Levels of Treatment for the Jail Setting**

There is currently no single prototype for jail substance abuse
treatment programs, but rather a range of available programs that vary
in content and intensity according to the inmates' length of stay and
program goals in a particular jail. In the following layered approach,
each successive level of treatment includes service components from the
previous level.

***Level I: Brief Treatment***

For many inmates incarcerated 30 days or less, case management,
referral, and brief interventions can be provided. Brief treatment is
usually focused on supplying information and making referrals. Core
elements of Level I treatment include

-   *Motivational enhancement therapy and motivational interviewing:*
    Materials developed at Texas Christian University (TCU) include a
    board game called Downward Spiral, which helps clients examine the
    consequences of substance abuse. Another useful exercise is the
    Decision Matrix, which looks at the advantages and disadvantages of
    continued drug use from the client's perspective. See chapter 8 of
    TIP 44 (pp. 168-169) for more information on motivational
    enhancement therapy and motivational interviewing.

-   *Substance abuse education:* Films, presentations, and literature
    can be used to present this information.

-   *Information on available community resources:* Information can
    range from how to access healthcare services in the community to
    which community organizations offer substance abuse treatment.
    Clients can be referred to AA and NA (see note above), and
    counselors can provide help with finding job training programs,
    general educational programs, clothing, food, and public assistance.
    However, counselors should first check to see that an agency will
    accept referrals from the criminal justice system.

-   *Community linkage and transition services:* Jail aftercare
    coordinators or treatment counselors, community resource
    coordinators, and case managers often help to facilitate aftercare
    or diversion. Specialized reintegration programs can be helpful in
    developing postrelease plans related to housing, aftercare, relapse
    prevention, and employment. See also TIP 30, *Continuity of Offender
    Treatment for Substance Use Disorders From Institution to Community*
    (CSAT 1998).

-   *Medication-assisted treatment---Education and adherence:* For a
    significant number of inmates with a history of opioid abuse or
    dependence, a review of available opioid treatment medications (such
    as methadone or oral buprenorphine products) may be useful; however,
    use of these medications in criminal justice settings has not been
    widespread.

***Level II: Short-Term Treatment***

Level II, short-term treatment (approximately 4--12 weeks in duration)
enables greater depth of involvement in the treatment process. Level II
treatment interventions provide a focus on coping skills to prevent
substance use and to sustain recovery.

-   *Drug cravings, urges, and relapse prevention:* Returning to live
    with family members who actively use substances or condone substance
    use within the home creates additional high-risk situations for the
    offender. Counselors should assess the home situation and possibly
    examine alternative housing arrangements.

-   *Self-help programs:* Shown to be valuable and accessible in the
    criminal justice setting, NA and AA make up the majority of
    self-help programs available in these environments. In addition,
    some jails offer other peer support groups, such as those based on
    cognitive--behavioral therapy.

-   *Basic cognitive skills training:* Cognitive skills training helps
    inmates to correct thoughts that can lead to criminal behavior and
    substance abuse. These interventions help inmates to understand the
    relationship between thoughts, emotions, and behaviors. The training
    teaches strategies to address maladaptive thought processes that can
    lead to interpersonal conflict, emotional disturbance, and
    aggressive and violent behavior.

-   *Strengths building:* Researchers at TCU have developed a series of
    readiness and induction interventions that incorporate a
    strengths-building strategy and are designed specifically to
    overcome problems often encountered in working with those mandated
    to treatment. These activities can be used in groups of up to 35
    participants or in individual counseling. For more information on
    these interventions, see chapter 8 of TIP 44.

-   *Communication skills:* Key activities often address effective means
    of expressing anger and other negative emotions, dealing with
    conflict situations, and dealing with problems that arise in
    personal relationships at work or at home.

Other useful Level II interventions include anger management, safety
from domestic violence, problemsolving, and social skills training.

***Level III: Long-Term Treatment***

For inmates incarcerated more than 90 days, counselors can build on the
tools provided in short-term treatment and aid the inmate in the
transition back to the community. Long-term treatment approaches include
components similar to those found in residential treatment in many
community-based programs.

-   *Employment counseling:* Employment counseling can be incorporated
    into work release or furlough. Counselors should provide
    pre-employment training (e.g*.*, communication skills with
    employers, responsibility, punctuality) and assistance with a
    résumé. To elicit information to strengthen a résumé, clinicians can
    ask such questions as what a client has done as a volunteer,
    community member, or in jail that contributes to employment
    opportunities.

-   *Building a therapeutic community:* Limited duration TCs have been
    established in some jail programs. For a more complete discussion of
    therapeutic communities, see the following section of this Quick
    Guide and also chapter 9 of TIP 44.

-   *Family mapping and social networks:* The purpose of family mapping
    is to try to understand the family's criminal and/or substance use
    history and how the family adapted over the years in an effort to
    maintain stability. Inmates look beyond their immediate families,
    since many criminal and substance-using behaviors move across
    generations. For some issues it may be important to have the family
    present.

-   *Co-occurring disorders:* Key interventions include psychiatric
    consultation to review medications, education regarding mental
    disorders, and development of transition plans for followup mental
    health and substance abuse services in the community.

-   *Criminal thinking:* By identifying and challenging maladaptive
    criminal thinking patterns such as generalizations, absolutes,
    exaggerations, and lies, offenders can become more critical in their
    thinking and question the thoughts that lead to criminal behavior.
    For more information on criminal thinking, see the section of this
    Quick Guide titled *General Treatment Issues in the Criminal Justice
    System* (above) and also chapter 5 of TIP 44.

**TREATMENT ISSUES IN PRISONS**

Prisons differ from jails in that inmates generally serve longer periods
of time (1 year or longer) and offenders have often committed serious or
repeated crimes. Types of prisons include---

-   Intake facilities (processing centers for inmates receiving
    orientation, medical examinations, and psychological assessment)

-   Community facilities (halfway houses, work farms, prerelease
    centers, transitional living facilities, low-security programs for
    nonviolent inmates)

-   Minimum security prisons (dormitory-style housing for inmates
    classified as the lowest risk levels serving relatively short
    sentences for nonviolent crimes)

-   Medium security prisons (higher security risks such as those with a
    history of violence)

-   Maximum security prisons (most restrictive prisons for violent
    inmates and those posing the highest security risks)

-   Multi-use prisons (inmates of different security classifications
    generally used in States with smaller prison populations)

-   Specialty prisons (for inmates with specific needs, such as people
    with mental illness, physical disabilities, or HIV/AIDS).

**Trauma and Hopelessness**

Prisons can be violent, harsh, psychologically damaging environments.
Inmates' responses to prison environments vary, but virtually all will
experience some degree of trauma and hopelessness. A review of the
literature indicates that inmates most likely to have difficulty coping
in prison have unstable family, living, work, and/or education
histories; are single, young, and male; and exhibit histories of chronic
substance abuse or psychological problems.

When accompanied by violence and exploitation from other inmates or
custodial staff, the sense of trauma and hopelessness can be magnified.
Sexual assaults are particularly devastating, with a series of
accompanying medical, psychological, and social problems. Even for
inmates who do not suffer abuse or exploitation while in prison, the
trauma of incarceration alone may worsen existing posttraumatic stress
disorder (PTSD) or create PTSD-like symptoms (see below for a list of
PTSD markers).

**Gender-Specific Issues**

Prison populations are segregated by gender. In addition to the
difference in psychosocial issues facing male and female inmates, the
character and experience of men's and women's prisons are widely
different.

***Men***

For many incarcerated men, learning to express anger in constructive
ways is vital. Violence prevention groups explore thoughts, feelings,
and behaviors that often underlie violent behavior and sexual
aggression. Issues related to relationships and fatherhood should also
be explored. Employing both male and female counselors is helpful in an
all-male program, as male inmates may be less guarded and
confrontational with female staff.

***Women***

Compared to male inmates, incarcerated women are more likely to have
mental disorders, to be HIV positive, to have been physically or
sexually abused, and to have a history of trauma. Female inmates with
substance use disorders have poorer employment histories than male
counterparts and are likely to have fewer job opportunities.
Imprisonment also disrupts family life, thereby interfering with roles
as wife/partner, mother, sister, etc. For many women, their identity is
tied to one or more of these roles, and interference can cause stress
and trigger substance abuse.

For more information on gender-specific issues in substance abuse
treatment, see chapter 6 of TIP 44, and also the forthcoming TIPs
*Substance Abuse Treatment: Addressing the Specific Needs of Women* and
*Substance Abuse Treatment and Men's Issues* (both CSAT in development).

**Suggested Treatment Services for This Setting**

Because those in prison tend to be incarcerated for longer periods than
jail inmates, treatment possibilities in a prison setting are more
extensive, depending on funding and other variables.

***Treatment Components***

In its prison study, the National Center on Addiction and Substance
Abuse at Columbia University found that 65 percent of prisons provide
substance abuse counseling. Of those, 98 percent offered group
counseling and 84 percent offered individual counseling.

-   *Group counseling:* The intensity and duration of group therapy can
    vary, but the basic objective is to provide an emotionally safe
    environment where participants can engage in meaningful change.
    Trained professionals typically lead groups of 8 to 10 inmates
    several times a week. Sessions are generally 1 to 2 hours.

-   *Cognitive--behavioral groups:* Cognitive/behavioral/social learning
    models emphasize interventions that assist the offender in changing
    criminal beliefs and values. Examples include NIC's *Thinking for a
    Change* curricula, the *Criminal Conduct and Substance Abuse
    Treatment*, and others described in chapter 5 of TIP 44.

-   *Rational--emotive behavior therapy (REBT):* In REBT, the client's
    thinking patterns are the focus of attention. Individuals who abuse
    substances tend to think automatically, in rigid terms, and with
    overgeneralizations and rationalizations. Clients are taught to be
    aware of their thinking patterns and to challenge their assumptions.

-   *Specialty groups:* Specialty groups are often organized around a
    shared experience (e.g., children of alcoholics, incest survivors,
    persons with AIDS) or a common problem (anger management, parenting,
    stress reduction). Anger management groups can be helpful for
    inmates who are passive, non-assertive, or express anger in an
    explosive fashion.

-   *Family counseling:* Involvement of a family member in an
    individual's treatment program can help prepare the individual for
    parole. However, caution needs to be exercised when involving
    families of offenders because of the risk of antisocial behavior and
    psychological disturbance in the family dynamic.

-   *Individual counseling:* Inmates in individual counseling and
    therapy may feel more free to explore sensitive issues, which they
    might not be ready to discuss in a group.

-   *Educational and vocational training:* The acquisition of skills
    such as basic literacy, GED certification, and life skills can
    increase employment opportunities and improve self-esteem. These
    services are generally provided by the prison and must be closely
    coordinated and monitored by the treatment staff as part of case
    management functions.

-   *Self-help groups:* Self-help groups are particularly important in
    developing a personal identity and providing a pathway to recovery
    from substance use disorders. Also, they help to develop social
    support during re-establishment in the community. At times,
    compulsory self-help group attendance is used as a sanction;
    however, this is ill advised and can be detrimental to other
    treatment efforts.

***Therapeutic Techniques***

In addition to motivational interviewing, faith-based initiatives, token
economy models, and more traditional medical--pharmacological models,
the following interventions have been widely used in correctional
treatment and have gained clinical validity among many practitioners:

-   *Role playing:* Role playing takes advantage of the fact that
    inmates are experienced at playing roles negatively and directs that
    skill toward a positive end. For example, inmates who have been
    perpetrators of violence can be asked to play the role of the victim
    as a way of helping them experience the emotions and thoughts of
    their victims.

-   *Video feedback:* Video feedback allows inmates to "see themselves
    as others see them." Viewing a tape of their intake interview might
    help inmates be more aware of their own body postures, gestures, and
    facial expressions. Video sessions can also help inmates identify
    different behavior patterns, attitudes, and issues about their
    self-images they might want to change.

-   *"Blended" approaches:* Blended approaches expand in-prison
    treatment offerings to include more innovative techniques and
    treatment modalities. For example, one approach at the South Idaho
    Correctional Institution blended cognitive--behavioral therapy,
    12-Step programming, and TC components to deliver an innovative
    program for parole violators who abuse substances. See chapter 9 of
    TIP 44 (p. 199) for more information on blended approaches.

***In-Prison Therapeutic Communities***

Offshoots of the mental health and self-help approaches, TCs are among
the most successful in-prison treatment programs. Because of the
intensity of treatment, TCs are preferable for the placement of
offenders assessed as substance dependent. The Federal Bureau of Prisons
and State systems in California, Delaware, New York, Oregon, and Texas,
among others, have well-established TC programs in place. Some evidence
shows that prison-based TC programs may provide the best results for
those whose residency extends from 9 to 12 months. Relapse can be
relatively high, however, if continuity of care is not provided after
release from custody.

The general goals of TCs are (1) abstinence from substance use, (2)
cessation of criminal behavior, (3) employment and/or school enrollment,
and (4) successful social adjustment. Prison TCs maintain a high level
of control over their participants, and treatment goals are always
secondary to security. Although the structure of these programs can
vary, most are a minimum of 6 months in duration and consist of three or
four stages:

-   Orientation to acquaint inmates with the rules of the TC and
    establishes routines

-   Group and individual counseling to work on issues of recovery

-   Maintaining recovery and relapse prevention

-   Reentry planning

***Treatment Intensity***

Treatment in prisons can vary greatly in the setting and intensity of
the program, ranging from TCs to counseling, educational, and other
treatment services delivered in a manner similar to outpatient services.

**TREATMENT ISSUES FOR OFFENDERS UNDER COMMUNITY SUPERVISION**

Both parolees and probationers are under community supervision;
nonetheless, they represent different ends of the criminal justice
continuum. Whereas parolees and mandatory releasees are serving a term
of conditional supervised release following a prison term, probationers
are under community supervision instead of a prison or jail term.

Parolees and probationers are alike in that their freedom is
conditional; both groups must meet certain conditions in order to avoid
incarceration or reincarceration. Treatment for drug or alcohol
dependency is often one of those conditions. Although their freedom is
curtailed, parolees and probationers have greater access to drugs and
alcohol than the incarcerated population and hence more opportunities to
relapse.

**Treatment Levels and Treatment Components**

The section titled "Triage and Placement" provides information on
selecting the appropriate treatment level. This section builds on that
material to provide information specific to offenders under community
supervision.

***Residential***

For offenders under community supervision, the most used residential
model is the TC, which provides a structured, 24-hour treatment
environment. Other residential programs are recovery homes for employed
offender-clients, with evening and weekend treatment and limited on-site
staff. Facilities may include hospitals or hospital-based programs,
institutional housing, sections of apartment complexes, and
dormitory-like residences. Most residential treatment programs use a
group-centered approach to create an environment that duplicates certain
aspects of a family and makes clients accountable to their peers.
Residential treatment should be followed by continued care in an
outpatient setting.

***Outpatient***

Outpatient treatment ranges from traditional services, provided in
regularly scheduled sessions in a group or individual setting, to
intensive treatment such as day or evening programs in which clients
engage in a full spectrum of services while living at home or in a
special residence. Offenders may initially be placed in residential
settings, followed by intensive outpatient treatment and continuing
care. Because outpatient treatment tends to be more intense in community
settings, offenders may receive more intense treatment than during
incarceration.

***Halfway Houses***

Halfway houses, when run by the criminal justice system, are
transitional facilities where clients are involved in school, work,
training, and other activities; they may or may not include direct
substance abuse treatment. A halfway house can be a step up to greater
liberty (i.e., for a person released from prison) or a step down for an
offender in need of greater supervision (i.e., for a person who violated
probation requirements). Usually individual counseling is provided,
along with group, family, or couples therapy. House responsibilities are
shared, and rules must be followed. The length of stay may be related to
sentence length and depend on individual progress.

***Day Reporting***

Day reporting centers are facilities to which offenders must report in
person or by phone from a job or treatment site. Day centers may provide
assessment for special needs and such services as anger management, drug
testing, GED preparation, drug and medical/mental health treatment,
violence prevention, community service, and vocational training. Some
day centers function primarily as staging areas from which offenders are
sent out in work crews. Others offer educational opportunities. In many
jurisdictions, day centers have become day treatment centers whose
primary mission is to provide outpatient substance abuse treatment of
various intensities, provided by public or private treatment agencies or
correctional agency staff.

**Suggested Treatment Services for People Under Community Supervision**

-   *Housing:* A lack of housing for offenders under community
    corrections supervision is a major problem in most jurisdictions.
    Available housing often is inconvenient to jobs, public
    transportation routes, community social services, or other agencies
    and includes drug-involved family members and/or friends. Sometimes
    halfway houses, "sober houses," or recovery houses are better
    alternatives than the offender-client's home.

-   *Reintegration with family members and social support:* Often the
    offender's home environment is not conducive to treatment adherence.
    Treatment providers should explore the family's dynamics during a
    home visit and make alternative living arrangements if the
    environment threatens to undermine treatment. To supplement the
    support an offender may be receiving from family members, the
    treatment plan should include recreation and other outlets to build
    healthy social relationships.

-   *Vocational training and employment:* Vocational training should
    occur before employment. If the client has not undergone treatment
    or training, there is a high risk that money earned will be spent on
    drugs or alcohol, which commonly results in losing the job.

-   *Case management:* Joint case management between the criminal
    justice and treatment systems rests on the foundation of two
    agreements: the agreement between the client and the two systems
    laying out protocols and consequences of infractions and the
    agreement between the two agencies. This agreement, or memorandum of
    understanding (MOU), defines how each will manage the caseload of
    offender-clients in the jurisdiction.

-   *Relapse prevention:* Relapse prevention training must be provided
    throughout treatment and stressed prior to release. When relapse
    occurs, clients must be helped to understand that it is part of the
    recovery process rather than a personal failure. Because a return to
    drug abuse can lead to a resumption of criminal activity, graduated
    sanctions for relapses should be specified in the treatment plan. It
    is essential that personnel from both the criminal justice and
    treatment systems agree to the range of responses and times when
    certain responses are appropriate.

**TREATMENT ISSUES FOR SPECIFIC POPULATIONS**

*See above for a discussion of gender-based treatment issues.*

**Clients With Children**

Under the Adoption and Safe Families Act of 1997, parents of children in
foster care for 15 or more of the past 22 months can have their parental
rights terminated. Given that the average prison term for incarcerated
women is 15 months, an increasing number of parents permanently lose
custody of their children---often a devastating blow for mothers and
their children.

If children are removed, criminal justice and treatment providers must
consider providing assistance for dealing with grief and loss. A client
who has demonstrated a sustained period of sobriety during treatment
should be considered for a phased return of her children. Mothers
re-entering the community from correctional institutions are likely to
have a difficult time reuniting with their children. They and their
children should work with family service agencies for a specified
period, to smooth the transition.

**Sexual Orientation**

Incarcerated individuals may engage in sexual activity with members of
the same gender for many reasons, not all of which reflect their sexual
identity. Despite disciplinary codes in jails and prisons that prohibit
all sexual activity, such behavior still occurs. A social hierarchy
based on sexual roles is common within men's prisons. Although
middle-aged and older men are most likely to abstain from sexual
activity while incarcerated, others engage in sexual behaviors to assert
their masculinity, to establish power over others and over their own
lives, and, in the case of stable relationships, to provide
companionship.

Other issues related to sexual orientation, such as conflicts with the
family of origin and societal discrimination, can create additional
stress that can lead to substance use.

**Persons With Co-Occurring Disorders**

The National GAINS Center for People with Co-occurring Disorders in the
Justice System provides an online resource for those who work with
offenders. The GAINS Center collects and analyzes information, develops
materials specifically for people who work with offenders with mental
illnesses, and provides technical assistance to help localities plan,
implement, and operate appropriate, cost-effective programs. For more
information, visit gainscenter.samhsa.gov.

**Clients With Psychological and Emotional Problems**

Offenders with severe substance use disorders have relatively high rates
of affective disorders, anxiety disorders, and personality disorders.
Although the treatment of co-occurring severe mental disorders and
substance use disorders is sometimes provided in specialized, more
intensive programs, the less severe mental disorders that do not cause
major functional impairment can be treated and managed effectively
within mainstream programs. The following are some commonly encountered
disorders:

-   *PTSD:* Markers of PTSD include irritability, hypervigilance, sleep
    difficulties, restricted range of affect, feelings of detachment,
    and flashbacks or nightmares of traumatic incidents. Counselors
    should be able to recognize these symptoms and refer clients to
    mental health professionals for further assessment and treatment.
    For more information on PTSD, see the forthcoming TIP *Substance
    Abuse and Trauma* (CSAT in development).

-   *Depression:* Markers of depression include inability to function at
    work or home, suicidal thoughts, loss of appetite, sleep
    difficulties, and weight changes. These symptoms require referral
    for further assessment and treatment. For more information on
    depression, see TIP 42, *Substance Abuse Treatment for Persons With
    Co-Occurring Disorders* (CSAT 2005).

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-   *Serious Mental Disorders:* Serious mental disorders (including
    schizophrenia, delusional disorder, bipolar disorder, and major
    depression), behavioral disorders that involve self-harm (e.g.,
    cutting or burning oneself, suicidal threats or attempts), and
    impulsive and uncontrollable aggression require involvement of
    mental health professionals for diagnostic workup and treatment
    interventions. After the more severe symptoms have abated (usually
    through medication and behavioral management in a specialized unit
    or a hospital), collaboration between mental health and substance
    abuse professionals can determine the best approach to manage and
    treat the individual.

-   *Intermittent Explosive Disorder:* When a client exhibits
    intermittent threatening behavioral disorder frequently, managing
    the individual in a mainstream program generally proves impractical.
    If the behaviors are infrequent, a mainstream setting may work, but
    only with additional assessment of the causes and perpetuating
    factors. The treatment plan will often involve a behavior contract.

-   *Borderline Personality Disorder:* Dialectical Behavior Therapy
    (DBT) has been specifically developed for treatment of BPD. This
    treatment requires specialized training, and manualized
    interventions are available to guide group treatment sessions. DBT
    approaches can be successfully integrated with substance abuse
    treatment in much the same way that the treatment of severe mental
    disorders is coordinated with mainstream substance abuse treatment.
    Clients participating in DBT do so on a voluntary basis. For more
    information on DBT see TIP 42, *Substance Abuse Treatment for
    Persons With Co-Occurring Disorders* (CSAT 2005).

**Cognitive/Learning, Physical, and Sensory Disabilities**

Given the prevalence of disabilities in incarcerated populations,
especially among offenders with substance use disorders, treatment
providers must be able to screen for co-existing disabilities and make
accommodations for the offenders who have them. For example, offenders
who have learning disabilities or low intelligence may not be able to
participate in a traditional TC and may need to be sent to a modified TC
or another suitable treatment program. Certain physical disabilities
require medication at times that may conflict with the times scheduled
for other activities.

Clients under community supervision require a support system that can
help them manage their medication and compliance. Clients who have
conditions that require the administration of medication by means of a
syringe face what could be a significant trigger for substance use. In
the community, they will have to contend with the theft or use of their
syringes by others. These clients will need assistance in developing a
relapse prevention plan.

For more information on assisting clients with co-existing disabilities,
see TIP 29, *Substance Use Disorder Treatment for People With Physical
and Cognitive Disabilities* (CSAT 1998).

**Older Adults**

Research indicates that approximately 2 percent of those incarcerated in
U.S. prisons are aged 55 or older. Many, though not all, of these
inmates have spent much of their lives in prison and do not know how to
live outside of such a unique environment, with physical barriers to the
outside world and the development of a unique way of life ("prison
culture"). This situation can produce what has been called
"disculturation," as prison rules and mores outweigh the norms of the
outside world. The usual milestones to measure success and adult rites
of passage (marriage, raising children, career, education, etc.) are
systematically denied the aging inmate, thus producing a sense of social
disconnection.

Older offenders have other unique issues that counselors should be
prepared to address, including---

-   Increased likelihood of health problems;

-   A slow response to directions;

-   The possibility of a physical condition presenting as an emotional
    or behavioral problem (e.g., Parkinson disease can present initially
    as depression, and some forms of dementia can first be expressed as
    behavioral or personality changes);

-   Lifelong patterns of criminal behavior that cannot be easily
    altered; and

-   A lack of assertiveness, suggesting that younger, more verbal
    inmates are more likely to get treatment.

Age is a factor associated with positive treatment outcomes. Similarly,
engagement for the elderly offender may be relatively easy. One of the
best ways to engage elderly inmates is to involve them in helping other
inmates. The program at the R.J. Donovan Correctional Facility is
highlighted in chapter 9 of TIP 44 as an example of a treatment approach
that can be beneficial to both the aging prison population and its
younger peers.

For more information on substance abuse treatment for older clients, see
TIP 26, *Substance Abuse Among Older Adults* (CSAT 1998), and chapter 9
of TIP 44.

**Clients From Rural Areas**

Clients coming from rural communities have a distinct culture that
differs from region to region. Treatment staff should seek to understand
these cultures in the same way they would any other.

Increasingly, offenders from urban areas are being sent to prisons in
rural regions, staffed by local residents; here again, a cultural clash
can develop, and correctional staff may need training in order to
understand differing cultural backgrounds.

Services in rural areas tend to be limited. Rural jails are generally
unable to develop treatment programs due to a lack of resources.
Community supervision programs in rural areas also have particular
difficulties. Few programs may be available, coordination between
programs may be infrequent, privacy and confidentiality may be difficult
to maintain, and certain types of substance abuse (e.g., excessive
alcohol consumption) may be the norm in the area.

**Sex Offenders**

In 1998, nearly 9 percent of the inmates in State prisons were
incarcerated on sex-related offenses. Among incarcerated sex offenders,
two of every three have a history of alcohol or drug use, abuse, or
addiction. Several barriers to successful treatment of sex offenders in
correctional institutions have been identified:

-   *Stigma:* Sex offenders are perceived as occupying the lowest
    possible rung within the prison social hierarchy, not only among
    inmates, but also among custodial and often treatment staff. This
    leads to secrecy and fear of self-disclosure based on a legitimate
    fear for their own safety.

-   *Untrained and inexperienced staff:* Most treatment staff in
    prison-based substance abuse programs lack the requisite knowledge
    to work effectively with sex offenders. This can be remedied in part
    by recruiting and hiring individuals with advanced degrees, special
    certification, or experience in substance abuse treatment, although
    it will entail increased treatment costs.

-   *Institutional policies against disclosure:* Strict prohibitions
    against disclosing inmate offense and conviction information means
    that staff are unable to identify which inmates are sex offenders.

-   *Lack of a formal process for identifying sex offenders with a
    psychiatric sexual disorder:* The different classifications of those
    who have committed sex-related offenses and those diagnosed with
    sex-related disorders makes identification more difficult for
    providers. Diagnosis of a sex offender, even with the inmate's
    criminal record, is often difficult.

Treatment should be based on a psychiatric diagnosis of a sex offender,
not just on legal offenses. Steps in the process include identifying
those sex offenders suitable for treatment, identifying the appropriate
treatment modality, and maximizing success by providing needed
aftercare. For more detailed information on sex offenders, see chapter 6
of TIP 44.

**GLOSSARY**

**Adult offender:** In most States people 18 or older are considered
adult offenders and processed through the adult criminal justice system,
but in three States people 16 or older are processed as adults and in
some other States it is 17 or older.

**Arrest:** The physical taking of a person into custody on the grounds
that there is probable cause to believe he or she has committed a
criminal offense. An arrest may follow an investigation by law
enforcement and is authorized by a warrant issued by a court.

**Bail**: Security (usually financial) provided as a guarantee that an
arrested person will appear for trial; release from imprisonment based
on that security.

**Conditional release:** Release from custody under specified
conditions.

**Court-mandated treatment:** A court order to participate in treatment
as part of a sentence or in lieu of some aspect of the judicial process.

**Day reporting center:** An intermediate sanction, this is a place
where offenders on probation or parole must report to receive
supervision for a certain number of hours each day. These centers may
include educational services, vocational or skills training, and other
service delivery. Offenders may also report by phone from a job or
treatment site during the day.

**Drug courts/Drug treatment courts:** Specialized courts commonly
designed to handle only felony drug cases, usually involving adult
nonviolent offenders. Drug courts can involve intensive monitoring, drug
testing, outpatient treatment, and support services. They often operate
with probation supervision and services.

**Halfway house:** A transitional facility where a client is involved in
school, work, training, etc. The client lives onsite while either
stabilizing or re-entering society drug free. The client usually
receives individual counseling, as well as group/family/marital therapy.
He or she may leave the site only for work, school, or treatment. This
facility can be in the community or attached to a jail or similar
institution.

**Mandatory release:** Required release of an inmate from incarceration
upon the expiration of a certain period, as stipulated by a determinate
sentencing law or by parole guidelines.

**Memorandum of understanding (MOU):** A written but noncontractual
agreement between two or more agencies or other parties to take a
certain course of action.

**Parole:** The conditional release of an inmate from prison under
supervision after part of a sentence has been served. The inmate is
subject to specific terms and conditions, which are monitored by an
officer/agent.

**Pretrial stage:** Activities in the criminal justice process that
occur between arrest and trial.

**Recidivism:** The commission of crime after an offender has been
sentenced and/or released.

**Skills training:** This includes job and vocational skills, life
skills (budgeting, leisure, etc.), literacy and GED classes, anger
management, general coping skills, communication skills, parenting
classes, building families and relationships, and social skills.

**Work release**: An alternative to total incarceration, whereby inmates
are permitted to work for pay in the free community but must return to a
secure facility during their nonworking hours.

**ORDERING INFORMATION**

**TIP 44: *Substance Abuse Treatment for Adults in the Criminal Justice
System***

**Tip 44-Related Products**

-   KAP Keys for Clinicians

-   Training Manual

-   Consumer Guide to Treatment Services in the Criminal Justice System

Do not reproduce or distribute this publication for a fee without the
specific, written authorization from the Office of Communications,
Substance Abuse and Mental Health Services Administration.

**Three Ways to Obtain FREE Copies**

**of All TIPs Products:**

1.  Call SAMHSA's National Clearinghouse for Alcohol and Drug
    Information (NCADI) at **800-729-6686,** TDD (hearing impaired)
    **800-487-4889.**

2.  Visit NCADI's Web site at **www.ncadi.samhsa.gov.**

3.  You can also access TIPs online at **www.kap.samhsa.gov.**

**Other Treatment Improvement Protocols that are relevant to this Quick
Guide**

-   **TIP 21:** *Combining Alcohol and Other Drug Abuse Treatment With
    Diversion for Juveniles in the Justice System* **BKD169**

-   **TIP 23:** *Treatment Drug Courts: Integrating Substance Abuse
    Treatment With Legal Case Processing* **BKD205**

-   **TIP 30:** *Continuity of Offender Treatment for Substance Use
    Disorders From Institution to Community* **BKD304**

-   **TIP 38:** *Integrating Substance Abuse Treatment and Vocational
    Services* **BKD381**

-   **TIP 41:** *Substance Abuse Treatment: Group Therapy* **BKD507**

-   *Substance Abuse and Trauma* (Due for publication in 2006)

See above for ordering information for all TIPs and related products.

DHHS Publication No. (SMA) 06-4149

Printed 2006